Presented by Jaclyn Coffey PharmD PGY1 Pharmacy Resident Norman Regional Health System Norman OK 1 Abstract 11 IRB Approved Disclosure Jaclyn Coffey Potential conflicts of interest none ID: 908525
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Impact of skin testing for penicillin allergy in self-reported penicillin allergic patients on the use of fluoroquinolones, carbapenems, aztreonam and vancomycin in a community hospital
Presented by: Jaclyn Coffey, PharmDPGY1 Pharmacy ResidentNorman Regional Health System, Norman OK
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Abstract #
11
IRB Approved
Slide2Disclosure
Jaclyn CoffeyPotential conflicts of interest: noneSponsorship: noneProprietary information or results of ongoing research may be subject to different interpretationsSpeaker’s presentation is educational in nature and indicates agreement to abide by the non-commercialism guidelines provided.
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Slide3Objectives
Describe potential benefits of penicillin skin testingIdentify patients that are ideal candidates for penicillin skin testing
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Slide4BackgroundLess than 10% of patients reporting a penicillin allergy are truly allergic
About 80% of patients with IgE-mediated penicillin allergy lose their sensitivity after 10 yearsPatients with a reported penicillin allergy have fewer treatment options
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Slide5Penicillin Skin Testing
Used to determine if a patient will have an IgE mediated allergic reaction to antibiotics in the penicillin class97-99% negative predictive value
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Slide6Penicillin Skin TestingTwo steps
Scratch testIntradermal testSolutionsHistamine (Histarol®) – positive control
Normal saline – negative controlBenzylpenicilloyl polylysine (PRE-PEN®)Diluted penicillin G (10,000 units/mL)Duration: about 1 hour
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Slide7Step 1: Scratch Test
Photo is reproduced with
permission from ALK
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Slide8Step 2: Intradermal Test
Photo is reproduced with
permission from ALK
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Slide9Study DesignObservational
Non-randomizedApproved by the Institutional Review Board
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Slide10Norman Regional Health SystemPorter, Healthplex, and Moore campuses
387 licensed bedsAcute care community hospital with a full range of services
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Slide11PurposeDecrease the use of fluoroquinolones, carbapenems, aztreonam, and vancomycin
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Slide12Methods
Phase 1Phase 2
Phase 3Initial data collectionImplementation of penicillin skin testingSubsequent data collection to evaluate impact
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Slide13Phase 1
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Slide14ResultsData collection over 4 weeks (September 2017)
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Slide15Reaction to Penicillin Antibiotic
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Slide16Antibiotics
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Slide17Phase 2 – In ProcessIncluded patients will be screened by a clinical pharmacist using a standardized questionnaire
Patients that meet inclusion criteria will undergo penicillin skin testingThe clinical pharmacist will recommend appropriate changes to the patients antibiotic regimen
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Slide18Inclusion CriteriaPatients 18 years of age and olderSelf-reported penicillin allergy
Penicillin or beta-lactam antibiotic is the drug of choicePatient reports a type 1 hypersensitivity reaction to penicillin that occurred greater than 5 years agoPatient signs a consent form
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Slide19Exclusion CriteriaPatient reports an immediate reaction (within 1 hour) to a penicillin antibiotic within the last 5 years
Patient has taken a histamine antagonists in past 48 hours (If unsure, a positive histamine scratch test will clarify), but may include if physician writes an order to hold the antihistaminePatient reports a severe skin reaction such as Steven’s-Johnson syndrome or toxic epidermal necrolysisPatient reports a non-IgE-mediated reaction such as vasculitis, interstitial nephritis, blistering rash, fever, mucous membrane involvement, joint involvement, cytopenia, or hemolysisRecent anaphylaxis within 4 weeksPatient has an intolerance to the antibiotic (i.e. stomach upset), not a true allergy, but may offer skin testing if patient refuses to take a penicillin antibiotic after they are educated
Patients with discharge ordersInsufficient skin amenable for interpretation of the testPregnancy History of a skin condition that could interfere with accurate reading of test resultsDiagnosis of human immunodeficiency virus infection and a CD4+ T-lymphocyte count of <500 cells/mm3 or history of opportunistic infectionCystic fibrosisNeutropenia (absolute neutrophil count of <1000 cells/mm3)Patients who only require peri-procedural antibioticsCritically ill patients (on vasopressors, mechanical ventilation, etc.)
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Slide20Process for ImplementationPharmacy & Therapeutics approval for PRE-PEN®Policy approval
Medical staffOrganizationalOrder set Create rule in clinical surveillance softwareNurse training to administer the testPharmacist training to screen patients and order testIT department for management of allergy information in the EHR
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Slide21ObstaclesAnaphylaxis risk
Who can obtain consentHow to order the testHow to avoid retesting and/or having the allergy added back to the patients EHR
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Slide22Phase 3 – in ProcessData collection in the same manner as phase 1
Measure the impact of penicillin skin testing
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Slide23Preliminary DataData collection over 2 weeks (April 23 through May 4)
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Slide24Patient 1 – Day 118 year old femaleAdmitted to ICU for hypotension, acute kidney injury, and urosepsis
Penicillin allergy is unknown from childhoodInitial antibiotics included vancomycin and meropenem
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Slide25Patient 1 – Day 2De-escalated to meropenem monotherapyPenicillin skin test was performed and was negative
Changed meropenem to piperacillin/tazobactam
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Slide26Patient 1 - ResultsAvoided 4 doses of meropenemPatient was discharged home with 7 days of ciprofloxacin for pan-sensitive E. coli UTI
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Slide27Patient 2 – Day 169 year old female
Admitted for possible right knee prosthetic joint infection s/p hardware removal and antibiotic spacer placementPenicillin allergic, but discovered on interview she tolerates cephalexinEmpiric treatment started with vancomycin
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Slide28Patient 2 – Day 5Patient changed from vancomycin to ceftaroline per infectious disease physicianPatient requires ceftaroline through 6/12/18
Penicillin skin test performed per patient request and was negative
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Slide29Patient 2 - ResultsChanged to ceftaroline based on interviewAvoided 39 days of vancomycin
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Slide30New BarriersPhysicians prefer fluoroquinolones for certain indications (UTI, COPD exacerbation, pneumonia, etc.)
Only making kits at Porter campusGray areas in policy
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Slide31Self-Assessment Questions
Potential benefits of penicillin skin testing includeAbility to use preferred antibioticsAbility to use less expensive antibiotics
Ability to use antibiotics with fewer side effectsAll of the aboveAn ideal candidate for penicillin skin testing has the following characteristic(s)Anaphylaxis to penicillin 1 year agoReported allergy to ciprofloxacinReported rash to amoxicillin 15 years agoReported toxic epidermal necrolysis to penicillin
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