Hospitalized Pneumonia Patients Who Have Unconfirmed Penicillin/Cephalosporin Allergy Likely to Receive Suboptimal Treatment
Key findings
- This nationwide study of data from 95 acute-care hospitals investigated the treatment of 2,276 inpatients who received antibiotics to treat pneumonia
- 20% of patients had a penicillin and/or cephalosporin (P/C) allergy recorded in their chart, and they were 21% less likely to receive a guideline-recommended first-line beta-lactam than those without a P/C allergy
- Recorded P/C allergy was also associated with an increased risk of treatment with a fluoroquinolone (52% increased use) or a carbapenem (61% increased use)
- Patients with high-risk P/C allergy histories were 53% less likely to receive first-line beta-lactams and were even more likely to receive a fluoroquinolone (1.6x increased risk) or a carbapenem (2x increased use)
- Hospitals should create protocols for disproving inaccurate P/C allergies and thereby increase the prescribing of guideline-recommended antibodies to patients with pneumonia
For inpatient treatment of pneumonia, the Infectious Disease Society of America recommends a narrow-spectrum beta-lactam antibiotic as part of first-line treatment. Beta-lactam antibiotics are generally more effective and less toxic than other antimicrobials, and ceftriaxone is safe even for patients with a history of high-risk penicillin reactions (e.g., anaphylaxis).
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However, patients who have a penicillin and/or cephalosporin (P/C) allergy recorded in their chart—even if self-reported and never observed or confirmed—frequently receive a broader-spectrum beta-lactam or a beta-lactam alternative. These agents may lead to inferior treatment outcomes or increase the risk of harm, including adverse effects leading to discontinuation of therapy, Clostridium difficile colitis or multidrug-resistant organisms.
Researchers at Massachusetts General Hospital have conducted the largest and most comprehensive U.S. study to date that investigated how P/C allergy affects the treatment of inpatient pneumonia. Patients with a P/C allergy recorded in their charts were treated less commonly with guideline-indicated beta-lactam antibiotics, they found, and more commonly with fluoroquinolones and carbapenems.
Christian M. Mancini, BS, of the Division of Rheumatology, Allergy and Immunology at Mass General, Kimberly Blumenthal, MD, MSc, quality and safety officer for Allergy and co-director of the Clinical Epidemiology Program in the division, Megan Wimmer, PharmD, of the University of Wisconsin Health, and colleagues detail the findings in The Journal of Allergy and Clinical Immunology: In Practice.
Methods
The researchers partnered with Vizient, Inc., a health care performance improvement company that represents more than 3,200 acute-care hospitals in the U.S., including more than 95% of academic medical centers. Member hospitals submitted data on inpatients receiving any antibiotic from October 16, 2018, through January 13, 2019.
95 short-term acute-care hospitals reported treating 2,276 patients for pneumonia. 450 patients (20%) had a P/C allergy reported in their electronic health record, and 91 patients (20% of the allergy group) had high-risk P/C allergies.
The primary outcome was the administration of a guideline-recommended beta-lactam: piperacillin–tazobactam, ceftriaxone, cefepime or ceftazidime.
Overall Cohort
Compared to patients without a recorded P/C allergy, patients with such an allergy were less likely to receive:
- Any guideline-recommended first-line beta-lactam—57% without a recorded P/C allergy vs. 44% with a recorded P/C allergy (P<0.001)
- Penicillin—33% vs. 11% (P<0.001)
- Third-generation cephalosporins—23% vs. 18% (P=0.01)
- Fourth-generation cephalosporins—13% vs. 20% (P<0.001)
On multivariable analysis, patients with a P/C allergy were:
- Less likely to receive a guideline-recommended first-line beta-lactam—adjusted prevalence ratio (aPR), 0.79
- More likely to receive a carbapenem—aPR, 1.61
- More likely to receive a fluoroquinolone—aPR,1.52
Patients With High-risk Allergies
Patients with high-risk P/C allergies were:
- Less likely to receive a guideline-recommended first-line beta-lactam than patients without a documented P/C allergy—aPR, 0.47
- More likely to receive a carbapenem—aPR, 2.22
- More likely to receive a fluoroquinolone—aPR, 1.56
Recommendations for Hospital Administrators, Antimicrobial Stewardship Programs
According to previous research, up to 95% of patients who report a P/C allergy may be able to tolerate penicillin and other beta-lactam antibiotics. Hospitals should identify methods to disprove/verify P/C allergies and thereby increase the prescribing of guideline-recommended antibiotics to patients with pneumonia.
In this study, just 38% of hospitals offered inpatient allergy consultation, and 29% offered inpatient penicillin skin testing. In hospitals that lack these services, institutional protocols could recommend using the reaction history to guide trials of first-line beta-lactams, with the indicated drug given in a two-step observed procedure.
Another strategy is to administer amoxicillin to inpatients who have a low-risk penicillin allergy, with the goal of disproving the allergy.
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