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Beta-Lactam Antibiotic Allergy Evaluation Guideline

Beta-Lactam Antibiotic Allergy Evaluation Guideline. Rationale Antibiotic prescribing can be improved in patients with reported beta-lactam antibiotic allergies Most patients with a reported penicillin (PCN) and/or cephalosporin allergy can tolerate a number of beta-lactam antibiotics

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Beta-Lactam Antibiotic Allergy Evaluation Guideline

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  1. Beta-Lactam Antibiotic Allergy Evaluation Guideline Rationale Antibiotic prescribing can be improved in patients with reported beta-lactam antibiotic allergies • Most patients with a reported penicillin (PCN) and/or cephalosporin allergy can tolerate a number of beta-lactam antibiotics • Over-cautious avoidance of all PCN/cephs in patients with a reported PCN/ceph allergy negatively impacts clinical outcomes • A guideline for prescribing antibiotics in patients with reported beta-lactam antibiotic allergies will improve clinical care (10-15% of the population report PCN allergy) Purpose Guide antibiotic prescribing in patients with reported beta-lactam antibiotic allergies

  2. Type of Reaction and Recommended Management cephalosporin

  3. Penicillin Allergy Pathway cephalosporin

  4. Cephalosporin Allergy Pathway cephalosporin

  5. Test Dose Protocol • Safe procedure can be performed by primary team on floor • PRN medications to be readily available on the floor: • Epinephrine, Benadryl, Hydrocortisone, Albuterol, Glucagon

  6. Next Steps

  7. Addressing Concerns about Test Dose:Provider Comfort • How will providers know the test dose exists? • Will publicize and educate providers • ASP and ID will guide providers initially to guideline • Allergy available 24 hours to address questions • Order set • Guideline  doesn’t have to be used, can always consult Allergy

  8. Addressing Concerns about Test Dose:Where will it be used? • Will the test dose delay surgery? • No. Guideline is not for use in PACU units, OR, strictly procedural units, obstetrics units, neonatal units, or emergency departments. • What about pediatric patients? • Plan is to go-live first for adult patients, then later for pediatric patients at Mission Bay

  9. Addressing Concerns about Test Dose:Nursing • Will nurses have to calculate the 1/10th dose? • No, all doses are pre-calculated in the order set

  10. Addressing Concerns about Test Dose:Safety • Can 1/10th of the dose lead to anaphylaxis in those with severe allergies? • Test dose is for patients who are unlikely to have reaction • Risk of patients with a known penicillin allergy reacting to 3rd/4th/5th-generation cephalosporin is the same as their risk of reacting to Bactrim • We would give a full dose of Bactrim to patients with a penicillin allergy

  11. Addressing Concerns about Test Dose:Safety Significantly increased beta-lactam antibiotic use No change in rate of adverse drug reactions Significantly decreased treatment with alternative antibiotics Blumenthal CID 2015

  12. Addressing Concerns about Test Dose:Safety • What about starting with smaller doses? • Not recommended • 3-step challenge with initial 1/100th dose  no difference in reaction rates or severity • Starting with smaller dose runs risk of desensitizing the patient instead of confirming tolerance Macy E, Romano A, Khan D. Practical Management of Antibiotic Hypersensitivity in 2017. JACI Pract 2017;5:577-86

  13. Addressing Concerns about Test Dose:Safety • Test doses are already being performed at UCSF • Guideline will provide education and order set needed to standardize and improve safety of test doses • Education – providers, nursing, pharmacy • Test dose order set • Calculation of 1/10th and full dose • Nursing orders for appropriate monitoring • PRN medications

  14. Addressing Concerns about Test Dose:Education & Dissemination • Nursing INEX • Pharmacy – • Pharmacy Grand Rounds & WGO • MD providers – • Otani and allergy colleagues are speaking at noon conferences / grand rounds • Allergy fellow is available 24 hours • Guideline recommended as part of Allergy and Infectious Disease 2018-2019 QI Initiative for all patients with ID consult

  15. Addressing Concerns about Test Dose:Recap • Test doses used safely as part of this guideline at other institutions • Test dose are being used per existing evidence-based guidelines – most of feedback is surrounding need for order set to standardize orders • Order set to standardize doses, medications, monitoring • Education – nursing, pharmacy, MD providers • Adult inpatients only • Dissemination partnered with Allergy and Infectious Disease 2018-2019 QI Initiative

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