Guideline/Protocol Title: |
Inpatient Beta-lactam Allergy Guideline |
Original Author(s): |
Iris M. Otani MD |
Collaborator(s): |
Antimicrobial Stewardship Programs |
Approving committee(s): |
P&T |
P&T Approval Date: |
Feb 14 2018 |
Last revision Date: |
12/09/2018, 01/10/2020, 03/15/2024 |
PURPOSE/SCOPE: |
To guide clinicians in prescribing antibiotics for pediatric and adult inpatients with known or suspected history of allergic reactions to penicillin or cephalosporin antibiotics. |
EXECUTIVE SUMMARY |
Patient Population: The information in this document provides recommendations for testing and safe antibiotic administration practices in patients with documented penicillin OR cephalosporin allergy. For patients with documented allergies to penicillin AND cephalosporin antibiotics, please Voalte on-call Allergy for assistance with beta-lactam antibiotic administration. Location: This guideline is for use on inpatient units. It is not for routine use in emergency departments, perioperative units (pre-operative holding areas, operating rooms, post-anesthesia care units), neonatal units, or obstetrics units. Please Voalte on-call Allergy if assistance is needed with beta-lactam antibiotic allergy evaluation in these settings. Test Dose: The test dose procedure that is described in this guideline is a safe procedure that can be performed by primary teams on inpatient units. Allergy consultation is not needed when the Test Dose is used as part of the Inpatient Beta-Lactam Allergy Guideline. Allergy approval is needed for the Test Dose to be performed for medications other than beta-lactam antibiotics. With Allergy approval, the Test Dose can be performed by primary teams on acute and transitional care units for medications other than beta-lactam antibiotics outside of the Inpatient Beta-Lactam Allergy Guideline.
On-Call Allergy Voalte: Consult Adult Allergy 1st Call and Consult Peds Allergy 1st Call |
BACKGROUND / INTRODUCTION |
Most patients with documented penicillin allergy do not have an active allergy [1]. Additionally, cross-reactivity rates between different beta-lactam antibiotics are low, and patients with testing-verified penicillin allergy can still safely receive many cephalosporins and all carbapenems [1]. Over-cautious avoidance of first-line beta-lactam antibiotics in patients with a documented penicillin has significant negative clinical impact. Inpatients with reported penicillin allergy have longer hospital stays, receive more alternative antibiotics, and have more drug-resistant infections [2]. A beta-lactam allergy guideline with recommendations for which antibiotics are safe to prescribe in patients with beta-lactam allergy can improve patient care by allowing these patients to receive more effective, less toxic, and/or less costly antibiotics [3]. The UCSF guideline has been approved since Feb 2018, and has had a significant positive impact on antibiotic prescribing practices [4]. Note: Although beta-lactam antibiotic allergy evaluations are recommended, use of this guideline should not delay care of an active infection. An alternative antibiotic per the primary team or Infectious Disease should be administered to treat active infection even if beta-lactam allergies have not been addressed. |
SUPPORTING EVIDENCE |
Penicillin Allergy (PA) Pathway – Appendix 2. Please see 2A for adult patients and 2B for pediatric patients.
Cephalosporin Allergy (CA) Pathway – Appendix 3. Please see 3A for adult patients and 3B for pediatric patients.
Definitions Beta-lactam antibiotics: antibiotics who chemical structure consists of a core beta-lactam ring with side chains – penicillin, cephalosporin, monobactam, carbapenem antibiotics Side chains: component of chemical structure of beta-lactam antibiotics that can be identical/similar or unique between certain beta-lactam antibiotics Adverse drug reaction: any adverse event due to pharmacologic effects of the drug Allergic reaction: adverse drug reaction mediated by IgE activation of allergy cells (mast cells, basophils) Type II-IV reaction: adverse drug reaction mediated by cells and proteins of the immune system but not involving IgE activation of allergy cells PEN-FAST: validated scoring system that identifies low-risk penicillin allergies that do not require formal allergy testing [6] |
APPENDIX |
Appendix 1: Determining the Type of Reaction and Recommended Management Appendix 2A: Penicillin Allergy (PA) Pathway – Adult Appendix 2B: Penicillin Allergy (PA) Pathway – Pediatric Appendix 3A: Cephalosporin Allergy (CA) Pathway – Adult Appendix 3B: Cephalosporin Allergy (CA) Pathway - Pediatric Appendix 4: Test Dose Procedure Appendix 5: Cross-Reactivity of Penicillin and Cephalosporin Antibiotics on Formulary at UCSF |
Reference # |
Citation |
1 |
Khan DA, Banerji A, Blumenthal KG, et al. Drug allergy: A 2022 practice parameter update. J Allergy Clin Immunol. 2022 Dec;150(6):1333-1393. PMID: 36122788. |
2 |
Macy E, Contreras R. Health care use and serious infection prevalence associated with penicillin “allergy” in hospitalized patients: A cohort study. J Allergy Clin Immunol. 2014 Mar;133(3):790-6. PMID: 24188976. |
3 |
Blumenthal KG, Shenoy ES, Varughese CA, et al. Impact of a clinical guideline for prescribing antibiotics to inpatients reporting penicillin or cephalosporin allergy. Ann Allergy Asthma Immunol. 2015 Oct;115(4):294-300.e2. PMID: 26070805 |
4 |
Otani IM, Tang M, Wang L, …, Doernberg SB. Impact of an Inpatient Allergy Guideline on β-Lactam and Alternative Antibiotic Use. J Allergy Clin Immunol Pract. 2023 Aug;11(8):2557-2567.e6. PMID: 37182569. |
5 |
Solensky R, Macy E. Minor determinants are essential for optimal penicillin allergy testing: a pro/con debate. J Allergy Clin Immunol Pract. 2015 Nov-Dec;3(6):883-7. PMID: 26164809. |
6 |
Trubiano JA, Vogrin S, Chua KYL, et al. Development and Validation of a Penicillin Allergy Clinical Decision Rule. JAMA Intern Med. 2020 May 1;180(5):745-752. PMID: 32176248 |
7 |
Blumenthal KG, Shenoy ES, Wolfson AR, et al. Addressing Inpatient Beta-Lactam Allergies: A Multihospital Implementation. J Allergy Clin Immunol Pract. 2017 May-Jun;5(3):616-625.e7. PMID: 28483315 |
Revision History |
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Revision Date |
Update(s) |
12/09/2018 |
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01/10/2020 |
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04/05/2024 |
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Appendix 1: Determining the Type of Reaction and Recommended Management
*SJS/TEN = Stevens-Johnson Syndrome / Toxic Epidermal Necrolysis; †DRESS/DISH = Drug-Induced Systemic Hypersensitivity/Drug Rash Eosinophilia and Systemic Symptoms
Appendix 2A: Penicillin Allergy (PA) Pathway - Adult
Appendix 2B: Penicillin Allergy (PA) Pathway – Pediatric
Appendix 3A: Cephalosporin Allergy (CA) Pathway – Adult