Record and Application to Allergy Triage for Inpatient Penicillin - PDF document

1/12/2019 Retrospective Review of Penicillin Allergy Documentation within an Electronic Medical Record and Application to Allergy Triage for Inpatient Penicillin Allergy Testing Hannah D. Fjeld, PharmD Candidate 1 ; Ryan W. Stevens, PharmD, BCIDP, BCPS 2 1 University of Alaska/Idaho State University College of Pharmacy; 2 Providence Alaska Medical Center Disclosures Authors of this presentation have the following to disclose concerning possible financial or personal relationships with commercial entities that may have a direct or indirect interest in the subject matter of this presentation. • Hannah D. Fjeld: Nothing to disclose • Ryan W. Stevens: Nothing to disclose 1

1/12/2019 Background • Penicillin (PCN) allergies are the most common self-reported allergy. • Estimated population prevalence of 10%. 1 • ~10% of reported penicillin allergies represent an IgE mediated process • Impact of PCN allergy listed in patient medical record • Cephalosporins are often withheld given concerns of a 3-5% risk of cross reactivity. 2 • Associated avoidance of beta-lactam antibiotics has been associated with adverse clinical outcomes, antibiotic resistance and higher cost of care. 2 • Penicillin skin testing (PST) is endorsed by the American Academy of Allergy Asthma and Immunology to be utilized for pts with self- reported PCN allergies. 3 Objective 1. Evaluate the number of pts who may be appropriate for inclusion in a PST protocol using comprehensive eMR review. 2. Evaluate the utility of the current eMR allergy documentation when used alone vs full eMR review to identify potential candidates for PST. 2

1/12/2019 Methods Inclusion Criteria: • Documented PCN allergy • Inpatient admission at index facility between 9/15/2016 and 9/14/2017 • Receipt of any antibiotic as an inpatient during above admission Exclusion Criteria: • Documented allergy to multiple beta-lactam classes (i.e. PCN and cephalosporin) 652 pts included for final review Current eMR Allergy Record Documentation Layout • Reaction Options • Reaction Type • Severity • Open Text Comments • Anaphylaxis • Allergy • High • Common Comments • Hives • Contraindication • Medium • Notes about • Shortness of Breath previously tolerating • Intolerance • Low • Swelling cephalosporin/ • Unspecified • {Blank} penicillin – either • Rash patient reported or in • {Blank} • Nausea and Vomiting patient exposure • Nausea Only • Notes about when • Diarrhea the reaction occurred (e.g. as a child, in • Itching 1958, etc.) • Sensitivity • Family history • Other (See Comments) • Unknown • {Blank} 3

1/12/2019 • Reaction Options Investigator Assigned Reaction Classification • Anaphylaxis • Hives IgE Mediated • Shortness of Breath • Swelling • Rash Non-IgE Mediated • Nausea and Vomiting Intolerance • Nausea Only • Diarrhea Adverse Reaction • Itching • Sensitivity Triaged • Other (See Comments) • Unknown Unknown • {Blank} Objective 1 Evaluate the number of pts who may be appropriate for inclusion in a PST protocol using comprehensive eMR review. 4

1/12/2019 283 pts 127 pts 166 pts 38 pts 28 pts 10 pts 43% 19% 26% 6% 4% 2% Give Cephalosporin 76 patients 5

1/12/2019 76 patients Give Cephalosporin 652 pts - 76 Give Ceph 576 remaining Has pt previously tolerated a cephalosporin and/or PCN within eMR? Yes No 100 pts 183 pts IgE Mediated (35%) (65%) Non-IgE 59 pts 68 pts Mediated (46%) (54%) 83 pts 83 pts Unknown (50%) (50%) Give Cephalosporin 242 pts 6

1/12/2019 652 pts 242 patients - 76 Give Ceph Give Cephalosporin - 242 Give Ceph - 183 PST 151 remaining 183 pts PST Unknown High Medium Low Non-IgE 2 pts 8 pts 6 pts 52 pts Mediated Unknown 76 pts 2 pts 3 pts 2 pts PST Give Cephalosporin Total 88 pts 63 pts 7

1/12/2019 652 pts - 76 Give Ceph - 242 Give Ceph - 183 PST - 88 PST - 63 Give Ceph 0 remaining 63 pts 88 pts Give Cephalosporin PST Evaluation From Full eMR Review Of 652 Patients: • 381 Give Cephalosporin • 271 PST 41.6% (n=271) of pts evaluated by full eMR review met inclusion criteria for PST. 8

1/12/2019 Objective 2 Evaluate the utility of the current eMR allergy documentation when used alone vs full eMR review to identify potential candidates for PST. 76 patients Give Cephalosporin 242 patients 69 patients Give Cephalosporin Give Cephalosporin Evaluation From Evaluation Utilizing Full eMR Review Allergy Record Alone 652 pts 652 pts 652 pts 652 pts 652 pts 652 pts 652 pts 652 pts 652 pts - 76 Give Ceph - 76 Give Ceph - 76 Give Ceph - 76 Give Ceph - 76 Give Ceph - 76 Give Ceph - 76 Give Ceph - 69 Give Ceph - 69 Give Ceph - 69 Give Ceph - 242 Give Ceph - 242 Give Ceph 247 pts 183 pts 576 remaining - 247 PST - 247 PST - 183 PST - 183 PST 576 remaining PST PST - 145 PST 507 remaining - 88 PST 260 remaining - 115 Give Ceph - 63 Give Ceph 151 remaining 0 remaining 0 remaining 115 pts 63 pts 145 pts 88 pts Give Cephalosporin Give Cephalosporin PST PST 9

1/12/2019 Results Evaluation Utilizing Evaluation From vs Allergy Record Alone Full eMR Review 60.1% (n=392) meet 41.6% (n=271) meet inclusion criteria for PST. inclusion criteria for PST. 32.1% (n=126) of the pts identified as candidates for PST using allergy record alone had no reaction, reaction severity or comments to assess allergy. Conclusions • Utility of the eMR allergy record to identify potential candidates for PST: • Does not appear to facilitate quick and/or accurate assessment of pts appropriateness for PST • Significant number of pts with allergies documented without an associated reaction or reaction severity • Further optimization of the eMR’s allergy documentation is needed • Recommendations for optimization: • Require “hard stops” for allergy reaction • Link reaction to associated severity and classification • Provide instructions within the record for obtaining comprehensive allergy history and definitions of reactions • Include options for previously tolerated beta-lactams 10

1/12/2019 References 1. Chen JR, Tarver SA, Alvarez KS, Tran T, Khan DA. A proactive approach to penicillin allergy testing in hospitalized patients. J Allergy Clin Immunol Pract. 2017 May - Jun;5(3):686-693. 2. Romano A, Valluzzi RL, Caruso C, Maggioletti M, Quaratino D, Gaeta F. Cross-reactivity and tolerability of cephalosporins in patients with IgE- mediated hypersensitivity to penicillins. J Allergy Clin Immunol Pract. 2018 Sep - Oct;6(5):1662-1672. 3. Penicillin allergy in antibiotic resistance workgroup. Penicillin allergy testing should be performed routinely in patients with self-reported penicillin allergy. J Allergy Clin Immunol Pract. 2017 Mar - Apr;5(2):333-334. Questions? Contact Information: fjelhann@isu.edu 11