Antibiotics Shuaib Nasser - PowerPoint Presentation

1. Antibiotics Shuaib NasserCambridge University Hospitals NHS Foundation TrustNAP6 Steering Committee member

2. Key FindingsAntibiotics most common cause of perioperative anaphylaxis in UK35% of all cases (NMBAs ≈25% of cases)Antibiotic anaphylaxis in 5.15 per 100,000 patients /yr receiving at least one antibiotic perioperatively 3.96 per 100,000 antibiotic administrations /yr develop antibiotic anaphylaxisCo-amoxiclav caused17.3% and teicoplanin 13.5% of the 35% total ie 89% of all casesPerioperative anaphylaxis incidence:Teicoplanin -16.39 per 100,000 administrations /yr, ie16-fold that of cefuroximeCo-amoxiclav -8.64 per 100,000 administrations /yr ie 9-fold that of cefuroximevancomycin was 3rd and piperacillin-tazobactam 4th place - distantMost common first clinical feature was hypotension - 42% of all antibiotic casespresented within 5 min of exposure in 76% of casesTwo fifths of the patients with a pre-operative history of penicillin allergy reacted to teicoplaninAllergy clinics did not identify the antibiotic culprits in 25% cases due to incomplete investigations ieskin tests and drug provocation challengesIn two thirds of cases inappropriate advice on future avoidance was given by allergy clinicsAllergy clinics may be underdiagnosing antibiotic allergy, potentially placing patients at risk

3. Antibiotic allergy reported pre-operatively Allergy toPenicillinCephalosporinOther antibioticPenicillin4534Cephalosporin322Other antibiotic4210total52716

4. Demographics –antibiotic allergy

5. Antibiotic culprits

6. Time interval from IV injection to first clinical feature

7. First Clinical Feature

8.

9. Grade of anaphylaxis for all antibioticsGradeAntibioticGrade 3Grade 4Grade 5allTotalTotalTotalTotalCo-amoxiclav2421146Teicoplanin1816236Cefuroxime 404Gentamicin3003Flucloxacillin1102Piperacillin-tazobactam0101Metronidazole1001Vancomycin1001Total4843394

10. Allergy clinic diagnosis of 92 cases of antibiotic anaphylaxisCulprit established by the review panelAllergy clinic diagnosis of antibiotic allergy with high certaintyAllergy clinic diagnosis of antibiotic allergy with intermediate certainty or certainty not statedNot investigated by Allergy clinic or culprit not identifiedAntibiotic number% of cases established by the review panelnumber% of cases established by the review panelnumber% of cases established by the review panelCo-amoxiclav462452.2%817.4%14a30.4%Flucloxacillin22100%00%00%Piperacillin-tazobactam100%1100%00%Cefuroxime4250.0%00%250.0%Teicoplanin361952.8%822.2%925.0%Vancomycin100%00%1100%Gentamicin3133.3%266.7%00%Metronidazole11100%00%00%Total945053.2%1920.2%2425.5%92 cases of antibiotic-induced anaphylaxis were identified by the review panelAllergy clinics considered 69 cases (50 definite) to have been caused by an antibiotic. But in some cases a single culprit was not confirmed and >2agents were recommended for avoidanceIn 12 cases the review panel considered that an oral challenge had been omitted by the allergy clinic In another 11 cases the review panel suggested IV drug provocation should have been consideredIn 61 /92 cases(66%) of antibiotic allergy identified by the review panel appropriate advice on future avoidance was not provided by the allergy clinic either not given, inappropriate due to incomplete investigation of all culprits and/or no culprit identified, no safe alternatives clearly stated, excessive avoidance advice (e.g. multiple antibiotics) based on incomplete investigations Ie. allergy clinics may be underdiagnosing antibiotic allergy potentially placing patients at risk

11. Antibiotic use & relative incidence of anaphylaxis AntibioticExposure from activity surveyUse in NAP6Cases suspected by anaesthetistAllergic reactions in NAP6*Incidence  Relative incidence Estimated annual caseloadTotal no% of all cases Total noTotal no% of all cases cases per 100,000 administrations per yearCefuroxime = 1Co-amoxiclav532,5807126.7%404617.3%8.649.16 Flucloxacillin211,973124.5%620.8%0.941.0Piperacillin-tazobactam28,23741.5%310.4%3.543.76Cefuroxime424,143166.0%641.5%0.941.0Teicoplanin219,6216223.3%333613.5%16.3917.38Vancomycin17,64841.5%310.4%5.676.01Gentamicin616,8995621.1%231.1%0.490.52Metronidazole272,173176.4%010.4%0.370.39Amoxicillin Data not collected41.5% 00%- CeftriaxoneData not collected31.1% 00%- CiprofloxacinData not collected20.8% 00%- ClindamycinData not collected20.8% 00%- MeropenemData not collected20.8% 00%- AmikacinData not collected10.4% 00%- Total2,323,274256  92(94)#34.6%(35.3%)3.96(4.05)4.20(4.29)Patients receiving at least one antibiotic1,787,360-- --5.15 5.46

12. RECOMMENDATIONSInstitutionalPatients with reported allergy to a beta-lactam antibiotic and at least one other class of antibiotics should be referred for allergy investigation, before elective surgery, in line with NICE CG183: Drug allergy: diagnosis and management.If antibiotic allergy is suspected despite negative skin tests, challenge testing should be consideredBroad beta lactam avoidance advice should be discouraged and patients should be further investigated to clarify the drug(s) to avoid and to identify safe alternatives.Individual Ninety per cent of anaphylaxis due to antibiotics presents within ten minutes of administration. When perioperative antibiotics are indicated they should be administered as early as possible, where practical at least 5-10 minutes before induction of anaesthesia, providing this does not interfere with their efficacy.The anaesthetist should consider co- amoxiclav or teicoplanin amongst the likely culprits when anaphylaxis occurs after their administration. Avoid test doses of antibiotic

13. Key FindingsAntibiotics most common cause of perioperative anaphylaxis in UK35% of all cases (NMBAs ≈25% of cases)Antibiotic anaphylaxis in 5.15 per 100,000 patients /yr receiving at least one antibiotic perioperatively 3.96 per 100,000 antibiotic administrations /yr develop antibiotic anaphylaxisCo-amoxiclav caused17.3% and teicoplanin 13.5% of the 35% total ie 89% of all casesPerioperative anaphylaxis incidence:Teicoplanin -16.39 per 100,000 administrations /yr, ie16-fold that of cefuroximeCo-amoxiclav -8.64 per 100,000 administrations /yr ie 9-fold that of cefuroximevancomycin was 3rd and piperacillin-tazobactam 4th place - distantMost common first clinical feature was hypotension - 42% of all antibiotic casespresented within 5 min of exposure in 76% of casesTwo fifths of the patients with a pre-operative history of penicillin allergy reacted to teicoplaninAllergy clinics did not identify the antibiotic culprits in 25% cases due to incomplete investigations ieskin tests and drug provocation challengesIn two thirds of cases inappropriate advice on future avoidance was given by allergy clinicsAllergy clinics may be underdiagnosing antibiotic allergy, potentially placing patients at risk

14. Thank you