Background: 15% of hospitalized patients have a documented penicillin (PCN) allergy. However, fewer than 1% of those patients have a true IgE-mediated reaction that necessitates avoidance of beta-lactam antibiotics. Labeling a patient with a PCN allergy is associated with prescribing non beta-lactam (NBL) broad spectrum antibiotics and increased adverse outcomes. Patients with a documented PCN allergy have 23% more Clostridioides difficile infections. We conducted a two-pronged quality intervention led and executed by medical and nursing students as part of a High-Value Care curriculum to explore this gap.
Methods: The 5-month intervention took place between June 2021-October 2021. The target population was prescribers on the internal medicine service at an 1100 bed urban academic tertiary care center. The intervention included an educational and electronic medical record (EMR) component. The educational component included virtual lectures on antibiotic prescribing best practices paired with a weekly in-person marketing campaign for residents, nurse practitioners, and physician assistants.in June and July. The EMR component included adding a link to antibiotic prescribing best practices directly in the EMR allergy history and developing a novel best practice alert (BPA) to notify the clinician if a patient with a PCN allergy had received a beta-lactam in the past. Pre and post intervention data were compared using chi-squared tests.
Results: Data showed a significant, sustained increase in the percent of beta-lactams prescribed for patients with a PCN allergy who have “other” or “unknown” as a reaction type (pre-intervention: 19%; post-intervention: 28%; p-value = 0.027). The data showed a statistically significant increase in the percent of beta-lactams prescribed to patients with a PCN allergy who have a documented low severity reaction (pre-intervention: 20%; post intervention: 26%; p-value = 0.043).These changes could reflect enhanced antibiotic stewardship for patients with low-risk PCN allergies. The beta-lactam history BPA included one NBL only, Aztreonam, for the pilot. The goal was to prove the safety of the BPA due to concerns of clinicians choosing an antibiotic that would trigger an allergic reaction. The BPA fired 11 times over the 5-month intervention. No adverse events were triggered by the BPA (no orders of epinephrine or ‘anaphylaxis order set’); highlighting the safety of the BPA. The BPA will need to be expanded to include additional non beta-lactam broad spectrum antibiotics in order to determine the effectiveness in changing orders to a more appropriate antibiotic.
Conclusions: The intervention was effective in increasing beta lactam usage for patients with a PCN allergy and either a low severity reaction or a reaction type of “other” and “unknown” and the change in behavior was sustained over 5 months. Future expansion of the beta-lactam history BPA to include additional NBLs will allow evaluation of effectiveness in changing antibiotic orders to beta-lactams for low-risk PCN allergy patients.