Fitch, Eryn

Slenker, Amy, MD

English

Lehigh Valley Health Network: LVHN Scholarly Works

Lehigh Valley Health NetworkLVHN Scholarly WorksResearch Scholars Poster PresentationImpact of a Documented Penicillin Allergy on Pre-Operative Antibiotic Prophylaxis Selection atLehigh Valley Health NetworkEryn FitchAmy Slenker MDLehigh Valley Health Network, amy_k.slenker@lvhn.orgFollow this and additional works at: https://scholarlyworks.lvhn.org/research-scholars-postersThis Poster is brought to you for free and open access by LVHN Scholarly Works. It has been accepted for inclusion in LVHN Scholarly Works by anauthorized administrator. For more information, please contact LibraryServices@lvhn.org.Published In/Presented AtFitch, E., Slenger, A., (2018, 3, August) Impact of a Documented Penicillin Allergy on Pre-Operative Antibiotic Prophylaxis Selection atLehigh Valley Health Network . Poster presented at LVHN Research Scholar Program Poster Session, Lehigh Valley Health Network,Allentown, PA.Lehigh Valley Health Network, Allentown, Pennsylvania20%27%4%3%1%0%0%25%5%1% 2%1% 5%0%1% 0%0%0%0%2%Type of Penicillin Reactions  Unknown Reaction (20%)Rash (27%)GI issues (4%)Itching (3%)Edema (1%)Dizziness (0%)Fever (0%)No reaction (0%)Hives (25%)Respiratory Distress (1%)Shortness of Breath (2%)Swelling (5%)Loss of Consciousness (0%)Throat Swelling/Closing (1%)Pruritis (1%)Palpitations (0%)Convulsions (0%)Cough/Wheezing (0%)Chest Tightness (0%)Miscellaneous Reactions (2%)0204060801001 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65Percentage of Surgeon's Procedures without Beta-lactam Use (%)Surgeons Assigned to an Anonymous Number Avoidance of Beta-lactams by Individual Providers in Penicillin-Allergic Pre-Operative Patients High Severity ReactionLow Severity Reaction• Penicillin allergy is reported by approximately 10% of patients, although it is estimated that 0.02-0.04% of the population actually have a true life-threatening allergy.1 Instead, the vast majority have experienced low severity or non-allergic adverse effects.2• Patients who report penicillin allergies are often treated with broad-spectrum antibiotics, specifically non-beta-lactam antibiotics, as an alternative to penicillin that can result in increased cost and increased risk for multidrug resistant infections and C. difficile colitis.1,3• This is a concern for pre-operative patients because a reported penicillin allergy is associated with a 50% increase in the risk of developing a surgical site infection.4• Purpose: Review LVHN’s current practice regarding pre-operative prophylaxis in the penicillin-allergic patient.• This study reveals an opportunity for improvement in the pre-operative prophylactic antibiotic choice in penicillin-allergic patients.  Only 53% of penicillin allergic patients with a low-severity reaction are receiving appropriate antibiotics.• This study reveals a need for education regarding penicillin allergies, appropriate choice of pre-operative antibiotics, the risks of avoiding beta-lactam antibiotics, and opportunities for outpatient penicillin skin testing. • We suggest the following to improve the usage of beta-lactams in the pre-operative patient population by:– Standardization of  guidance for how to proceed in patients with a low severity or non-allergic penicillin allergy – Maintain an accurate record regarding the patient’s antibiotic allergies – Consider large-scale implementation of pre-operative penicillin skin testing when the reaction type or severity is unknown BACKGROUNDMETHODSRESULTS DISCUSSIONCONCLUSIONSImpact of a Documented Penicillin Allergy on Pre-Operative Antibiotic Prophylaxis Selection at Lehigh Valley Health Network Eryn Fitch and Amy Slenker, MDOBJECTIVES1. Identify rates of penicillin allergy in the pre-operative patient population and how often these patients receive a beta-lactam antibiotic (cefazolin) as prophylaxis.2. Identify the types of reactions in the pre-operative penicillin-allergic patients and determine if the reaction severity is associated with the pre-operative antibiotic administered. 3. Identify if certain providers are more likely to avoid beta-lactam pre-operative antibiotics more frequently.Comparison of Pre-operative Antibiotic Administered based on the Severity of the Penicillin-associated Reactions • Reported penicillin allergies for surgical patients at LVHN was lower than the reported average in the general population (6% vs. 10%).• There were many different types of adverse reactions documented.  Forty-two percent of the reactions were high severity, 35% were low severity, and 23% were unknown (Figure 1). • There is an increase in the usage of pre-operative beta lactam antibiotics for low severity compared to high severity reactions (53% vs. 36%), although there is an opportunity for improvement as 47% of the patients with low severity reactions are not receiving appropriate pre-operative prophylaxis.  • There is an inconsistency with beta-lactam use among providers.  This could be due to lack of education on the advantages of using beta-lactams, lack of knowledge regarding when it is appropriate to challenge patients with a penicillin allergy, and lack of knowledge regarding the availability of outpatient penicillin skin testing. REFERENCES1. Gonzalez-Estrada, A. & Radojicic, C. (2015). Penicillin allergy: A practical guide for clinicians. Cleveland Clinic Journal of Medicine, 82 (5), 295-300.2. Chang, C., Mahmood, M.M., Teuber, S.S., Gershwin, M.E. (2012). Overview of penicillin allergy. Clinical reviews in allergy & immunology, 43 (1-2), 84-97.3. Blumenthal, K.G., Ryan, E.E., Li, Y., Lee, H., Kuhlen, J.L., Shenoy, E.S. (2018). The Impact of a Reported Penicillin Allergy on Surgical Site Infection Risk. Clinical Infectious Diseases, 66 (3), 329–336.4. Dellinger, E.P., Jain, R. & Pottinger, P.S. (2018). The Influence of Reported Penicillin Allergy. Clinical Infectious Diseases, 66 (3), 337–33.5. Bhattacharya, S. (2010).  The Facts about Penicillin Allergy: A Review. Journal of Advanced Pharmaceutical Technology & Research, 1 (1), 11-17.Figure 1: This is a count of documented penicillin-associated reactions. Penicillin-allergic patients may be counted more than once if they have multiple allergic reactions documented, but each patient is only counted once for reaction severity.5Type of Pre-Operative Antibiotic UsedDocumented Penicillin Reaction(n=1200)Low Severity Reaction(n=427)High Severity Reaction(n=500)Unknown Severity Reaction (n=273)Beta-lactam 540 (45%) 227 (53%) 180 (36%) 133 (49%)Non-beta-lactam Only660 (55%) 200 (47%) 320 (64%) 140 (51%)High SeverityLow SeverityRashFigure 2: Percentage of surgeries for individual providers with non-beta-lactam use for both high severity and low severity reactions. Surgeons must perform at least 5 surgeries on patients with a penicillin allergy to be included. 33,060 surgical procedures were performed at LVHN from October 1st,2017 to March 31st, 2018Excluded: •Non-penicillin-allergic patients•Surgical procedures without a pre-operative antibiotic (colonoscopy, EGD, and bronchoscopy)1,200 surgical procedures on penicillin-allergic patients with prophylactic antibiotic Unknown Severity Penicillin Allergy(n=273)Beta-lactam Antibiotic Prophylaxis  (n=180) Non-beta-lactam Antibiotic Prophylaxis  (n=320) High Severity Penicillin Allergy (n=500)Beta-lactam Antibiotic Prophylaxis (n=227) Non-beta-lactam Antibiotic Prophylaxis (n=200) Low Severity Penicillin Allergy (n=427) Beta-lactam Antibiotic Prophylaxis (n=133) Non-beta-lactam Antibiotic Prophylaxis (n=140) UnknownHivesTable 1: Penicillin-allergic patients were separated based on severity of reaction based on usage of a beta-lactam or non-beta-lactam antibiotic prophylaxis.High42%Low35%Unknown 23%Penicillin Reaction SeverityHighLowUnknown

Impact of a Documented Penicillin Allergy on Pre-Operative Antibiotic Prophylaxis Selection at Lehigh Valley Health Network

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Impact of a Documented Penicillin Allergy on Pre-Operative Antibiotic Prophylaxis Selection at Lehigh Valley Health Network

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