Impact of skin testing for penicillin allergy in self-reported penicillin allergic patients - PowerPoint Presentation

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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 #

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IRB Approved

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Disclosure

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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Objectives

Describe potential benefits of penicillin skin testingIdentify patients that are ideal candidates for penicillin skin testing

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BackgroundLess 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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Penicillin 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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Penicillin 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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Step 1: Scratch Test

Photo is reproduced with

permission from ALK

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Step 2: Intradermal Test

Photo is reproduced with

permission from ALK

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Study DesignObservational

Non-randomizedApproved by the Institutional Review Board

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Norman Regional Health SystemPorter, Healthplex, and Moore campuses

387 licensed bedsAcute care community hospital with a full range of services

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PurposeDecrease the use of fluoroquinolones, carbapenems, aztreonam, and vancomycin

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Methods

Phase 1Phase 2

Phase 3Initial data collectionImplementation of penicillin skin testingSubsequent data collection to evaluate impact

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Phase 1

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ResultsData collection over 4 weeks (September 2017)

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Reaction to Penicillin Antibiotic

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Antibiotics

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Phase 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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Inclusion 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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Exclusion 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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Process 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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ObstaclesAnaphylaxis 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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Phase 3 – in ProcessData collection in the same manner as phase 1

Measure the impact of penicillin skin testing

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Preliminary DataData collection over 2 weeks (April 23 through May 4)

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Patient 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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Patient 1 – Day 2De-escalated to meropenem monotherapyPenicillin skin test was performed and was negative

Changed meropenem to piperacillin/tazobactam

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Patient 1 - ResultsAvoided 4 doses of meropenemPatient was discharged home with 7 days of ciprofloxacin for pan-sensitive E. coli UTI

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Patient 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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Patient 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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Patient 2 - ResultsChanged to ceftaroline based on interviewAvoided 39 days of vancomycin

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New BarriersPhysicians prefer fluoroquinolones for certain indications (UTI, COPD exacerbation, pneumonia, etc.)

Only making kits at Porter campusGray areas in policy

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Self-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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