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Elizabeth J. Phillips - One of the best experts on this subject based on the ideXlab platform.
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children with reported Penicillin Allergy public health impact and safety of delabeling
Annals of Allergy Asthma & Immunology, 2020Co-Authors: David Vyles, Cosby A. Stone, Jason A. Trubiano, James W Antoon, Allison E Norton, Alexandra Radowicz, Elizabeth J. PhillipsAbstract:Abstract Objective To review the relevant literature related to children with reported Penicillin Allergy and highlight the different ways in which children could be delabeled and to evaluate the public health impact that a Penicillin Allergy has for children. Data Sources Data for this review were obtained via PubMed searches and then retrieval of articles from their respective journals for further review. Study Selections Studies regarding the safety of different ways to evaluate Penicillin Allergy in children were identified via PubMed searches. Any study that reported different ways of testing (3-tier, direct oral challenge, 5-day oral challenges) were included. This same format was used when selecting relevant articg:les related to the costs, prescription patterns, and stewardship trends associated with a Penicillin Allergy label. Results This review found that Penicillin Allergy testing is a safe and effective way to delabel those with reported Allergy. In children with low-risk Allergy symptoms, a direct oral challenge approach may be optimal. In those children with a history of high-risk Allergy symptoms, a 3-tiered approach is ideal. The review also found that there is a significant cost associated with reported Penicillin Allergy and that there are increased negative health benefits to those children with reported Allergy. Conclusion Penicillin Allergy is overdiagnosed, often incorrectly, and the label is frequently first applied during childhood. Targeting children for the removal of the incorrect Penicillin Allergy label provides a mechanism to reduce the use of broader-spectrum and less effective antibiotics.
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The challenge of de-labeling Penicillin Allergy.
Allergy, 2019Co-Authors: Cosby A. Stone, Jason A. Trubiano, David T. Coleman, Christine R.f. Rukasin, Elizabeth J. PhillipsAbstract:Background Even though 8%‐25% of most populations studied globally are labeled as Penicillin allergic, most diagnoses of Penicillin Allergy are made in childhood and relate to events that are either not allergic in nature, are low risk for immediate hypersensitivity, or are a potential true Allergy that has waned over time. Penicillin Allergy labels directly impact antimicrobial stewardship by leading to use of less effective and broader spectrum antimicrobials and are associated with antimicrobial resistance. They may also delay appropriate antimicrobial therapy and lead to increased risk of specific adverse healthcare outcomes. Operationalizing Penicillin Allergy de‐labeling into a new arm of antimicrobial stewardship programs (ASPs) has become an increasing global focus. Methods We performed an evidence‐based narrative review of the literature of Penicillin Allergy label carriage, the adverse effects of Penicillin Allergy labels, and current approaches and barriers to Penicillin Allergy de‐labeling. Over the period 1928‐2018 in Pubmed and Medline, search terms used included “Penicillin Allergy” or “Penicillin hypersensitivity” alone or in combination with “adverse events,” “testing,” “evaluation,” “effects,” “label,” “de‐labeling,” “prick or epicutaneous,” and “intradermal” skin testing, “oral challenge or provocation,” “cross‐reactivity,” and “antimicrobial stewardship”. Results Penicillin Allergy labels are highly prevalent, largely inaccurate and their carriage may lead to unnecessary treatment and inferior outcomes with alternative agents as well as adverse public health outcomes such as antibiotic resistance. Conclusions Operationalizing Penicillin Allergy de‐labeling as an aspect of ASP has become an increasing global focus. There is a need for validated approaches that optimally combine the use of history and ingestion challenge with or without proceeding formal skin testing to tackle Penicillin Allergy efficiently within complex healthcare systems. At the same time, there is great promise for Penicillin Allergy evaluation and de‐labeling as an individual and public health strategy to reduce adverse healthcare outcomes, improve antimicrobial stewardship, and decrease healthcare costs.
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antibiotic use after removal of Penicillin Allergy label
Pediatrics, 2018Co-Authors: David Vyles, Elizabeth J. Phillips, Asriani Chiu, John M Routes, Mariana Castells, Jennifer Kibicho, David C BrousseauAbstract:BACKGROUND: Penicillin Allergy is commonly reported in the pediatric emergency department. We previously performed 3-tier Penicillin Allergy testing on children with low-risk symptoms, and 100% tolerated a Penicillin challenge without an allergic reaction. We hypothesized that no serious allergic reactions would occur after re-exposure to Penicillin and that prescription practices would change after testing. METHODS: We performed a follow-up case series of 100 children whose test results were negative for Penicillin Allergy. Research staff administered a brief follow-up phone survey to the parent and primary care provider of each patient tested. We combined the survey data and summarized baseline patient characteristics and questionnaire responses. We then completed a 3-tier economic analysis from the prescription information gathered from surveys in which cost savings, cost avoidance, and potential cost savings were calculated. RESULTS: A total of 46 prescriptions in 36 patients were reported by the primary care provider and/or parents within the year after patients were tested for Penicillin Allergy. Twenty-six (58%) of the prescriptions filled were Penicillin derivatives. One (4%) child developed a rash 24 hours after starting the medication; no child developed a serious adverse reaction after being given a Penicillin challenge. We found that the cost savings of delabeling patients as Penicillin allergic was $1368.13, the cost avoidance was $1812.00, and the total potential cost savings for the pediatric emergency department population was $192 223.00. CONCLUSIONS: Children with low-risk Penicillin Allergy symptoms whose test results were negative for Penicillin Allergy tolerated a Penicillin challenge without a severe allergic reaction developing. Delabeling children changed prescription behavior and led to actual health care savings.
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Penicillin Allergy is not necessarily forever
JAMA, 2017Co-Authors: Jason A. Trubiano, Elizabeth J. Phillips, Franklin N AdkinsonAbstract:Penicillin Allergy is often diagnosed early in life, and the history of Penicillin Allergy persists in a patient’s medical record for many years without verification. Some physicians’ consideration of a patient having Penicillin Allergy is based on patient experience that may have occurred early in childhood. This results in the use of alternate antibiotics that are less effective, more toxic and expensive, and that have inappropriately broader coverage than Penicillin.1 Accumulating evidence suggests that excessive use of unnecessarily broad-spectrum antibiotics increases the risk of antibiotic resistance, including Clostridium difficile infection.2 The inability to use an antistaphylococcal Penicillin (eg, nafcillin) for patients with methicillin-susceptible Staphylococcus aureus sepsis or other serious infections for which Penicillins are the first-line therapy (eg, ampicillin for Enterococcus faecalis or benzathine Penicillin for syphilis) places patients at risk of treatment failure, resistance generation, and increased mortality.
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Penicillin Allergy label persists despite negative testing
The Journal of Allergy and Clinical Immunology: In Practice, 2015Co-Authors: Kali Svarczkopf Gerace, Elizabeth J. PhillipsAbstract:Studies support a public health imperative to de-label patients of Penicillin Allergy, however, “de-labeling” is only effective if acted upon. We hypothesized that persistence of a Penicillin Allergy label despite negative Penicillin testing (PT) would be prevalent, impairing the utility and cost-effectiveness of PT.
Jason A. Trubiano - One of the best experts on this subject based on the ideXlab platform.
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children with reported Penicillin Allergy public health impact and safety of delabeling
Annals of Allergy Asthma & Immunology, 2020Co-Authors: David Vyles, Cosby A. Stone, Jason A. Trubiano, James W Antoon, Allison E Norton, Alexandra Radowicz, Elizabeth J. PhillipsAbstract:Abstract Objective To review the relevant literature related to children with reported Penicillin Allergy and highlight the different ways in which children could be delabeled and to evaluate the public health impact that a Penicillin Allergy has for children. Data Sources Data for this review were obtained via PubMed searches and then retrieval of articles from their respective journals for further review. Study Selections Studies regarding the safety of different ways to evaluate Penicillin Allergy in children were identified via PubMed searches. Any study that reported different ways of testing (3-tier, direct oral challenge, 5-day oral challenges) were included. This same format was used when selecting relevant articg:les related to the costs, prescription patterns, and stewardship trends associated with a Penicillin Allergy label. Results This review found that Penicillin Allergy testing is a safe and effective way to delabel those with reported Allergy. In children with low-risk Allergy symptoms, a direct oral challenge approach may be optimal. In those children with a history of high-risk Allergy symptoms, a 3-tiered approach is ideal. The review also found that there is a significant cost associated with reported Penicillin Allergy and that there are increased negative health benefits to those children with reported Allergy. Conclusion Penicillin Allergy is overdiagnosed, often incorrectly, and the label is frequently first applied during childhood. Targeting children for the removal of the incorrect Penicillin Allergy label provides a mechanism to reduce the use of broader-spectrum and less effective antibiotics.
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development and validation of a Penicillin Allergy clinical decision rule
JAMA Internal Medicine, 2020Co-Authors: Cosby A. Stone, Jason A. Trubiano, Sara Vogrin, Kyra Y L Chua, Jack Bourke, Abby P Douglas, Roger Yu, Lauren Groenendijk, Natasha E HolmesAbstract:Importance: Penicillin Allergy is a significant public health issue for patients, antimicrobial stewardship programs, and health services. Validated clinical decision rules are urgently needed to identify low-risk Penicillin allergies that potentially do not require Penicillin skin testing by a specialist. Objective: To develop and validate a Penicillin Allergy clinical decision rule that enables point-of-care risk assessment of patient-reported Penicillin allergies. Design, Setting, and Participants: In this diagnostic study, a multicenter prospective antibiotic Allergy-tested cohort of 622 patients from 2 tertiary care sites in Melbourne, Australia (Austin Health and Peter MacCallum Cancer Centre) was used for derivation and internal validation of a Penicillin Allergy decision rule. Backward stepwise logistic regression was used to derive the model, including clinical variables predictive of a positive Penicillin Allergy test result. Internal validation of the final model used bootstrapped samples and the model scoring derived from the coefficients. External validation was performed in retrospective Penicillin Allergy-tested cohorts consisting of 945 patients from Sydney and Perth, Australia, and Nashville, Tennessee. Patients who reported a Penicillin Allergy underwent Penicillin Allergy testing using skin prick, intradermal, or patch testing and/or oral challenge (direct or after skin testing). Data were collected from June 26, 2008, to June 3, 2019, and analyzed from January 9 to 12, 2019. Main Outcomes and Measures: The primary outcome for the model was any positive result of Penicillin Allergy testing performed during outpatient or inpatient assessment. Results: From an internal derivation and validation cohort of 622 patients (367 female [59.0%]; median age, 60 [interquartile range{IQR}, 48-71] years) and an external validation cohort of 945 patients (662 female [70.1%]; median age, 55 [IQR, 38-68] years), the 4 features associated with a positive Penicillin Allergy test result on multivariable analysis were summarized in the mnemonic PEN-FAST: Penicillin Allergy, five or fewer years ago, anaphylaxis/angioedema, severe cutaneous adverse reaction (SCAR), and treatment required for Allergy episode. The major criteria included an Allergy event occurring 5 or fewer years ago (2 points) and anaphylaxis/angioedema or SCAR (2 points); the minor criterion (1 point), treatment required for an Allergy episode. Internal validation showed minimal mean optimism of 0.003 with internally validated area under the curve of 0.805. A cutoff of less than 3 points for PEN-FAST was chosen to classify a low risk of Penicillin Allergy, for which only 17 of 460 patients (3.7%) had positive results of Allergy testing, with a negative predictive value of 96.3% (95% CI, 94.1%-97.8%). External validation resulted in similar findings. Conclusions and Relevance: In this study, PEN-FAST was found to be a simple rule that accurately identified low-risk Penicillin allergies that do not require formal Allergy testing. The results suggest that a PEN-FAST score of less than 3, associated with a high negative predictive value, could be used by clinicians and antimicrobial stewardship programs to identify low-risk Penicillin allergies at the point of care.
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Penicillin Allergy: a practical approach to assessment and prescribing.
Australian Prescriber, 2019Co-Authors: Misha Devchand, Jason A. TrubianoAbstract:Penicillin allergies are not always lifelong. Approximately 50% are lost over five years A reaction to Penicillin during a childhood infection is unlikely to be a true Allergy Only 1–2% of patients with a confirmed Penicillin Allergy have an Allergy to cephalosporins. In patients with a low risk of severe allergic reactions, cephalosporins are a relatively safe treatment option Patients with a history of delayed non-severe reactions, such as mild childhood rashes that occurred over 10 years ago, may be suitable for an oral rechallenge with low-dose Penicillin. This should be done in a supervised hospital environment In many cases, with appropriate assessment and Allergy testing, it may be possible to remove the Penicillin Allergy label Keywords: beta-lactams, cephalosporins, hypersensitivity Introduction Most patients who say they have a Penicillin Allergy are not allergic to Penicillins. While 10% of the population will report a Penicillin Allergy, less than 1% will be truly allergic.1,2 They have been erroneously labelled as Penicillin-allergic. In the USA, Penicillin allergies are the most commonly documented drug Allergy, with up to 20% of hospitalised patients having a recorded Penicillin Allergy.3,4 In Australian hospitals, national point prevalence data (2013–14) show that 8.9% of patients have a Penicillin Allergy label on their medical record.5 A high proportion of these labels are likely to be incorrect. The patient may have had a non-immune-mediated reaction such as nausea and vomiting, an exanthema (e.g. after taking amoxicillin during an Epstein-Barr virus infection) or an injection-site reaction.6,7
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The challenge of de-labeling Penicillin Allergy.
Allergy, 2019Co-Authors: Cosby A. Stone, Jason A. Trubiano, David T. Coleman, Christine R.f. Rukasin, Elizabeth J. PhillipsAbstract:Background Even though 8%‐25% of most populations studied globally are labeled as Penicillin allergic, most diagnoses of Penicillin Allergy are made in childhood and relate to events that are either not allergic in nature, are low risk for immediate hypersensitivity, or are a potential true Allergy that has waned over time. Penicillin Allergy labels directly impact antimicrobial stewardship by leading to use of less effective and broader spectrum antimicrobials and are associated with antimicrobial resistance. They may also delay appropriate antimicrobial therapy and lead to increased risk of specific adverse healthcare outcomes. Operationalizing Penicillin Allergy de‐labeling into a new arm of antimicrobial stewardship programs (ASPs) has become an increasing global focus. Methods We performed an evidence‐based narrative review of the literature of Penicillin Allergy label carriage, the adverse effects of Penicillin Allergy labels, and current approaches and barriers to Penicillin Allergy de‐labeling. Over the period 1928‐2018 in Pubmed and Medline, search terms used included “Penicillin Allergy” or “Penicillin hypersensitivity” alone or in combination with “adverse events,” “testing,” “evaluation,” “effects,” “label,” “de‐labeling,” “prick or epicutaneous,” and “intradermal” skin testing, “oral challenge or provocation,” “cross‐reactivity,” and “antimicrobial stewardship”. Results Penicillin Allergy labels are highly prevalent, largely inaccurate and their carriage may lead to unnecessary treatment and inferior outcomes with alternative agents as well as adverse public health outcomes such as antibiotic resistance. Conclusions Operationalizing Penicillin Allergy de‐labeling as an aspect of ASP has become an increasing global focus. There is a need for validated approaches that optimally combine the use of history and ingestion challenge with or without proceeding formal skin testing to tackle Penicillin Allergy efficiently within complex healthcare systems. At the same time, there is great promise for Penicillin Allergy evaluation and de‐labeling as an individual and public health strategy to reduce adverse healthcare outcomes, improve antimicrobial stewardship, and decrease healthcare costs.
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Penicillin Allergy is not necessarily forever
JAMA, 2017Co-Authors: Jason A. Trubiano, Elizabeth J. Phillips, Franklin N AdkinsonAbstract:Penicillin Allergy is often diagnosed early in life, and the history of Penicillin Allergy persists in a patient’s medical record for many years without verification. Some physicians’ consideration of a patient having Penicillin Allergy is based on patient experience that may have occurred early in childhood. This results in the use of alternate antibiotics that are less effective, more toxic and expensive, and that have inappropriately broader coverage than Penicillin.1 Accumulating evidence suggests that excessive use of unnecessarily broad-spectrum antibiotics increases the risk of antibiotic resistance, including Clostridium difficile infection.2 The inability to use an antistaphylococcal Penicillin (eg, nafcillin) for patients with methicillin-susceptible Staphylococcus aureus sepsis or other serious infections for which Penicillins are the first-line therapy (eg, ampicillin for Enterococcus faecalis or benzathine Penicillin for syphilis) places patients at risk of treatment failure, resistance generation, and increased mortality.
David Vyles - One of the best experts on this subject based on the ideXlab platform.
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children with reported Penicillin Allergy public health impact and safety of delabeling
Annals of Allergy Asthma & Immunology, 2020Co-Authors: David Vyles, Cosby A. Stone, Jason A. Trubiano, James W Antoon, Allison E Norton, Alexandra Radowicz, Elizabeth J. PhillipsAbstract:Abstract Objective To review the relevant literature related to children with reported Penicillin Allergy and highlight the different ways in which children could be delabeled and to evaluate the public health impact that a Penicillin Allergy has for children. Data Sources Data for this review were obtained via PubMed searches and then retrieval of articles from their respective journals for further review. Study Selections Studies regarding the safety of different ways to evaluate Penicillin Allergy in children were identified via PubMed searches. Any study that reported different ways of testing (3-tier, direct oral challenge, 5-day oral challenges) were included. This same format was used when selecting relevant articg:les related to the costs, prescription patterns, and stewardship trends associated with a Penicillin Allergy label. Results This review found that Penicillin Allergy testing is a safe and effective way to delabel those with reported Allergy. In children with low-risk Allergy symptoms, a direct oral challenge approach may be optimal. In those children with a history of high-risk Allergy symptoms, a 3-tiered approach is ideal. The review also found that there is a significant cost associated with reported Penicillin Allergy and that there are increased negative health benefits to those children with reported Allergy. Conclusion Penicillin Allergy is overdiagnosed, often incorrectly, and the label is frequently first applied during childhood. Targeting children for the removal of the incorrect Penicillin Allergy label provides a mechanism to reduce the use of broader-spectrum and less effective antibiotics.
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who needs Penicillin Allergy testing
Annals of Allergy Asthma & Immunology, 2018Co-Authors: Eric Macy, David VylesAbstract:Key messages All individuals with an unconfirmed Penicillin Allergy should have their Penicillin Allergy evaluated, and if appropriate, tested to confirm current hypersensitivity or tolerance.
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antibiotic use after removal of Penicillin Allergy label
Pediatrics, 2018Co-Authors: David Vyles, Elizabeth J. Phillips, Asriani Chiu, John M Routes, Mariana Castells, Jennifer Kibicho, David C BrousseauAbstract:BACKGROUND: Penicillin Allergy is commonly reported in the pediatric emergency department. We previously performed 3-tier Penicillin Allergy testing on children with low-risk symptoms, and 100% tolerated a Penicillin challenge without an allergic reaction. We hypothesized that no serious allergic reactions would occur after re-exposure to Penicillin and that prescription practices would change after testing. METHODS: We performed a follow-up case series of 100 children whose test results were negative for Penicillin Allergy. Research staff administered a brief follow-up phone survey to the parent and primary care provider of each patient tested. We combined the survey data and summarized baseline patient characteristics and questionnaire responses. We then completed a 3-tier economic analysis from the prescription information gathered from surveys in which cost savings, cost avoidance, and potential cost savings were calculated. RESULTS: A total of 46 prescriptions in 36 patients were reported by the primary care provider and/or parents within the year after patients were tested for Penicillin Allergy. Twenty-six (58%) of the prescriptions filled were Penicillin derivatives. One (4%) child developed a rash 24 hours after starting the medication; no child developed a serious adverse reaction after being given a Penicillin challenge. We found that the cost savings of delabeling patients as Penicillin allergic was $1368.13, the cost avoidance was $1812.00, and the total potential cost savings for the pediatric emergency department population was $192 223.00. CONCLUSIONS: Children with low-risk Penicillin Allergy symptoms whose test results were negative for Penicillin Allergy tolerated a Penicillin challenge without a severe allergic reaction developing. Delabeling children changed prescription behavior and led to actual health care savings.
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Allergy testing in children with low risk Penicillin Allergy symptoms
Pediatrics, 2017Co-Authors: David Vyles, Juan Adams, Asriani Chiu, Pippa Simpson, Mark Nimmer, David C BrousseauAbstract:BACKGROUND: Penicillin Allergy is commonly reported in the pediatric emergency department (ED). True Penicillin Allergy is rare, yet the diagnosis results from the denial of first-line antibiotics. We hypothesize that all children presenting to the pediatric ED with symptoms deemed to be low-risk for immunoglobulin E-mediated hypersensitivity will return negative results for true Penicillin Allergy. METHODS: Parents of children aged 4 to 18 years old presenting to the pediatric ED with a history of parent-reported Penicillin Allergy completed an Allergy questionnaire. A prespecified 100 children categorized as low-risk on the basis of reported symptoms completed Penicillin Allergy testing by using a standard 3-tier testing process. The percent of children with negative Allergy testing results was calculated with a 95% confidence interval. RESULTS: Five hundred ninety-seven parents completed the questionnaire describing their child’s reported Allergy symptoms. Three hundred two (51%) children had low-risk symptoms and were eligible for testing. Of those, 100 children were tested for Penicillin Allergy. The median (interquartile range) age at testing was 9 years (5–12). The median (interquartile range) age at Allergy diagnosis was 1 year (9 months–3 years). Rash (97 [97%]) and itching (63 [63%]) were the most commonly reported Allergy symptoms. Overall, 100 children (100%; 95% confidence interval 96.4%–100%) were found to have negative results for Penicillin Allergy and had their labeled Penicillin Allergy removed from their medical record. CONCLUSIONS: All children categorized as low-risk by our Penicillin Allergy questionnaire were found to have negative results for true Penicillin Allergy. The utilization of this questionnaire in the pediatric ED may facilitate increased use of first-line Penicillin antibiotics.
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parent reported Penicillin Allergy symptoms in the pediatric emergency department
Academic Pediatrics, 2017Co-Authors: David Vyles, Juan Adams, Asriani Chiu, Pippa Simpson, Mark Nimmer, David C BrousseauAbstract:Abstract Objective Children often present to the pediatric emergency department (ED) with a reported Penicillin Allergy. The true incidence of pediatric Penicillin Allergy is low, and patients may be inappropriately denied first-line antibiotics. We hypothesized that more than 70% of reported Penicillin allergies in the pediatric ED are low risk for true Allergy. Methods Parents of children presenting to the pediatric ED with parent-reported Penicillin Allergy completed an Allergy questionnaire. The questionnaire included age at Allergy diagnosis, symptoms of Allergy, and time to allergic reaction from first dose. The Allergy symptoms were dichotomized into high and low risk in consultation with a pediatric allergist before questionnaire implementation. Results A total of 605 parents were approached; 500 (82.6%) completed the survey. The median (interquartile range) age of the children at diagnosis was 1 year (7 months, 2 years); 75% were diagnosed before their third birthday. Overall, 380 (76%) (95% confidence interval 72.3, 79.7) children had exclusively low-risk symptoms. The most commonly reported symptoms were rash (466, 92.8%) and itching (203, 40.6%). Of the 120 children with one or more high-risk symptom, facial swelling (50, 10%) was the most common. Overall, 354 children (71%) were diagnosed after their first exposure to Penicillin. Symptom onset within 24 hours of medication administration occurred in 274 children (54.8%). Conclusions Seventy-six percent of patients with parent-reported Penicillin Allergy have symptoms unlikely to be consistent with true Allergy. Determination of true Penicillin Allergy in patients with low-risk symptoms may permit the increased use of first-line Penicillin antibiotics.
Eric Macy - One of the best experts on this subject based on the ideXlab platform.
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Penicillin Allergy testing is cost saving an economic evaluation study
Clinical Infectious Diseases, 2020Co-Authors: Bernardo Sousapinto, Eric Macy, Kimberly G Blumenthal, Ana Margarida Pereira, Luis Azevedo, Luis Delgado, Joao FonsecaAbstract:BACKGROUND: Having a Penicillin Allergy label is associated with the use of less appropriate and more expensive antibiotics and increased healthcare utilization. Penicillin Allergy testing results in delabeling most Allergy claimants and may be cost-saving. This study aimed to project whether Penicillin Allergy testing in patients reporting a Penicillin Allergy is cost-saving. METHODS: In this economic evaluation study, we built decision models to project the economic impact of two strategies for the patient with a Penicillin Allergy label: (1) Perform diagnostic testing (drug challenges, with or without skin tests) and (2) Do not perform diagnostic testing. The health service perspective was adopted, considering costs with Penicillin Allergy tests, and with hospital bed-days/outpatient visits, antibiotic use, and diagnostic testing. Twenty-four base case decision models were built, accounting for differences in the diagnostic workup, setting (inpatient versus outpatient) and geographic region. Uncertainty was explored via probabilistic sensitivity analyses. RESULTS: Penicillin Allergy testing was cost-saving in all decision models built. For models assessing the performance of both skin tests and drug challenges, Allergy testing resulted in average savings of $657 for inpatients (United States of America: $1444, Europe: $489) and $2746 for outpatients (United States of America: $256, Europe: $6045). 75% of simulations obtained through probabilistic sensitivity analysis identified testing as the less costly option. CONCLUSION: Penicillin Allergy testing was projected to be cost-saving across different scenarios. These results are devised to inform guidelines, supporting the adoption of policies promoting widespread testing of patients with a Penicillin Allergy label.
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who needs Penicillin Allergy testing
Annals of Allergy Asthma & Immunology, 2018Co-Authors: Eric Macy, David VylesAbstract:Key messages All individuals with an unconfirmed Penicillin Allergy should have their Penicillin Allergy evaluated, and if appropriate, tested to confirm current hypersensitivity or tolerance.
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Penicillin Allergy optimizing diagnostic protocols public health implications and future research needs
Current Opinion in Allergy and Clinical Immunology, 2015Co-Authors: Eric MacyAbstract:Purpose of reviewUnverified Penicillin Allergy is being increasingly recognized as a public health concern. The ideal protocol for verifying true clinically significant IgE-mediated Penicillin Allergy needs to use only commercially available materials, be well tolerated and easy to perform in both t
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health care use and serious infection prevalence associated with Penicillin Allergy in hospitalized patients a cohort study
The Journal of Allergy and Clinical Immunology, 2014Co-Authors: Eric Macy, Richard ContrerasAbstract:Background Penicillin is the most common drug "Allergy" noted at hospital admission, although it is often inaccurate. Objective We sought to determine total hospital days, antibiotic exposures, and the prevalence rates of Clostridium difficile , methicillin-resistant Staphylococcus aureus (MRSA), and vancomycin-resistant Enterococcus (VRE) in patients with and without Penicillin "Allergy" at hospital admission. Methods We performed a retrospective, matched cohort study of subjects admitted to Kaiser Foundation hospitals in Southern California during 2010 through 2012. Results It was possible to match 51,582 (99.6% of all possible cases) unique hospitalized subjects with Penicillin "Allergy" to 2 unique discharge diagnosis category–matched, sex-matched, age-matched, and date of admission–matched control subjects each. Cases with Penicillin "Allergy" averaged 0.59 (9.9%; 95% CI, 0.47-0.71) more total hospital days during 20.1 ± 10.5 months of follow-up compared with control subjects. Cases were treated with significantly more fluoroquinolones, clindamycin, and vancomycin ( P C difficile , 14.1% (95% CI, 7.1% to 21.6%) more MRSA, and 30.1% (95% CI, 12.5% to 50.4%) more VRE infections than expected compared with control subjects. Conclusions A Penicillin "Allergy" history, although often inaccurate, is not a benign finding at hospital admission. Subjects with a Penicillin "Allergy" history spend significantly more time in the hospital. Subjects with a Penicillin "Allergy" history are exposed to significantly more antibiotics previously associated with C difficile and VRE. Drug "allergies" in general, but most those notably to Penicillin, are associated with increased hospital use and increased C difficile , MRSA, and VRE prevalence.
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safely diagnosing clinically significant Penicillin Allergy using only penicilloyl poly lysine Penicillin and oral amoxicillin
The Journal of Allergy and Clinical Immunology: In Practice, 2013Co-Authors: Eric Macy, Eunis W NgorAbstract:Background Penicillin skin testing is rarely used to undiagnose Penicillin "Allergy" in the United States, partially because of concern that commercially available materials are inadequate. Objective We determined whether skin testing with only commercially available penicilloyl-poly-lysine and Penicillin followed by an oral amoxicillin challenge, if skin test-negative, can safely identify clinically significant Penicillin Allergy. Methods Five hundred sequential persons with positive history of Penicillin "Allergy" were evaluated by skin testing with penicilloyl-poly-lysine and Penicillin between June 8, 2010, and March 29, 2012. All persons with negative skin tests were given an oral amoxicillin challenge and observed for 1 hour. Results Persons undergoing Penicillin Allergy testing were representative of all health plan members with Penicillin Allergy. Only 4 persons (0.8%; 95% CI, 0.32%-2.03%) had a positive skin test result. Only 4 persons (0.8%; 95% CI, 0.32%-2.03%) had an acute objective oral amoxicillin challenge reaction. Fifteen persons (3.0%; 95% CI, 1.83%-4.98%) had subjective oral challenge reactions, either acute transient itching or dizziness. All were women and 11 (73.3%) had multiple drug intolerance syndrome. None had severe reactions or objective signs. These were not considered to be positive challenge reactions. Sixty-eight subjects (13.6%) who were negative on testing were exposed to 88 courses of Penicillins during 90 days of follow-up. New reactions were reported after 4 courses (4.5%), 3 (75%) occurring in subjects with multiple drug intolerance syndrome. Conclusions Penicillin skin testing, using only penicilloyl-poly-lysine and Penicillin, followed by oral amoxicillin challenge, if negative, can safely identify clinically significant IgE-mediated Penicillin Allergy in patients who use health care in the United States at this time.
David C Brousseau - One of the best experts on this subject based on the ideXlab platform.
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antibiotic use after removal of Penicillin Allergy label
Pediatrics, 2018Co-Authors: David Vyles, Elizabeth J. Phillips, Asriani Chiu, John M Routes, Mariana Castells, Jennifer Kibicho, David C BrousseauAbstract:BACKGROUND: Penicillin Allergy is commonly reported in the pediatric emergency department. We previously performed 3-tier Penicillin Allergy testing on children with low-risk symptoms, and 100% tolerated a Penicillin challenge without an allergic reaction. We hypothesized that no serious allergic reactions would occur after re-exposure to Penicillin and that prescription practices would change after testing. METHODS: We performed a follow-up case series of 100 children whose test results were negative for Penicillin Allergy. Research staff administered a brief follow-up phone survey to the parent and primary care provider of each patient tested. We combined the survey data and summarized baseline patient characteristics and questionnaire responses. We then completed a 3-tier economic analysis from the prescription information gathered from surveys in which cost savings, cost avoidance, and potential cost savings were calculated. RESULTS: A total of 46 prescriptions in 36 patients were reported by the primary care provider and/or parents within the year after patients were tested for Penicillin Allergy. Twenty-six (58%) of the prescriptions filled were Penicillin derivatives. One (4%) child developed a rash 24 hours after starting the medication; no child developed a serious adverse reaction after being given a Penicillin challenge. We found that the cost savings of delabeling patients as Penicillin allergic was $1368.13, the cost avoidance was $1812.00, and the total potential cost savings for the pediatric emergency department population was $192 223.00. CONCLUSIONS: Children with low-risk Penicillin Allergy symptoms whose test results were negative for Penicillin Allergy tolerated a Penicillin challenge without a severe allergic reaction developing. Delabeling children changed prescription behavior and led to actual health care savings.
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Allergy testing in children with low risk Penicillin Allergy symptoms
Pediatrics, 2017Co-Authors: David Vyles, Juan Adams, Asriani Chiu, Pippa Simpson, Mark Nimmer, David C BrousseauAbstract:BACKGROUND: Penicillin Allergy is commonly reported in the pediatric emergency department (ED). True Penicillin Allergy is rare, yet the diagnosis results from the denial of first-line antibiotics. We hypothesize that all children presenting to the pediatric ED with symptoms deemed to be low-risk for immunoglobulin E-mediated hypersensitivity will return negative results for true Penicillin Allergy. METHODS: Parents of children aged 4 to 18 years old presenting to the pediatric ED with a history of parent-reported Penicillin Allergy completed an Allergy questionnaire. A prespecified 100 children categorized as low-risk on the basis of reported symptoms completed Penicillin Allergy testing by using a standard 3-tier testing process. The percent of children with negative Allergy testing results was calculated with a 95% confidence interval. RESULTS: Five hundred ninety-seven parents completed the questionnaire describing their child’s reported Allergy symptoms. Three hundred two (51%) children had low-risk symptoms and were eligible for testing. Of those, 100 children were tested for Penicillin Allergy. The median (interquartile range) age at testing was 9 years (5–12). The median (interquartile range) age at Allergy diagnosis was 1 year (9 months–3 years). Rash (97 [97%]) and itching (63 [63%]) were the most commonly reported Allergy symptoms. Overall, 100 children (100%; 95% confidence interval 96.4%–100%) were found to have negative results for Penicillin Allergy and had their labeled Penicillin Allergy removed from their medical record. CONCLUSIONS: All children categorized as low-risk by our Penicillin Allergy questionnaire were found to have negative results for true Penicillin Allergy. The utilization of this questionnaire in the pediatric ED may facilitate increased use of first-line Penicillin antibiotics.
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parent reported Penicillin Allergy symptoms in the pediatric emergency department
Academic Pediatrics, 2017Co-Authors: David Vyles, Juan Adams, Asriani Chiu, Pippa Simpson, Mark Nimmer, David C BrousseauAbstract:Abstract Objective Children often present to the pediatric emergency department (ED) with a reported Penicillin Allergy. The true incidence of pediatric Penicillin Allergy is low, and patients may be inappropriately denied first-line antibiotics. We hypothesized that more than 70% of reported Penicillin allergies in the pediatric ED are low risk for true Allergy. Methods Parents of children presenting to the pediatric ED with parent-reported Penicillin Allergy completed an Allergy questionnaire. The questionnaire included age at Allergy diagnosis, symptoms of Allergy, and time to allergic reaction from first dose. The Allergy symptoms were dichotomized into high and low risk in consultation with a pediatric allergist before questionnaire implementation. Results A total of 605 parents were approached; 500 (82.6%) completed the survey. The median (interquartile range) age of the children at diagnosis was 1 year (7 months, 2 years); 75% were diagnosed before their third birthday. Overall, 380 (76%) (95% confidence interval 72.3, 79.7) children had exclusively low-risk symptoms. The most commonly reported symptoms were rash (466, 92.8%) and itching (203, 40.6%). Of the 120 children with one or more high-risk symptom, facial swelling (50, 10%) was the most common. Overall, 354 children (71%) were diagnosed after their first exposure to Penicillin. Symptom onset within 24 hours of medication administration occurred in 274 children (54.8%). Conclusions Seventy-six percent of patients with parent-reported Penicillin Allergy have symptoms unlikely to be consistent with true Allergy. Determination of true Penicillin Allergy in patients with low-risk symptoms may permit the increased use of first-line Penicillin antibiotics.