Beta Lactam Allergy and Antimicrobial Stewardship Oct 12
Beta Lactam Allergy and Antimicrobial Stewardship Oct 12, 2017 Paul Bonnar and Andrea Kent paule. bonnar@nshealth. ca andrea. kent@nshealth. ca http: //www. cdha. nshealth. ca/nsha-antimicrobial-stewardship
NO DISCLOSURES
OBJECTIVES Identify the implications of beta lactam allergies on patient outcomes Explain the impact of beta lactam allergies on antimicrobial stewardship Identify strategies to use going forward to improve beta lactam allergy assessment in their practice Explain the purpose of an antimicrobial stewardship program Discuss further opportunities for antimicrobial stewardship interventions
What is Antimicrobial Stewardship? • Coordinated interventions designed to improve and measure the appropriate use of antimicrobials Right drug Right dose Right duration Right route Barlam. Clin Infect Dis. 2016; 62(10): e 51–e 77 Tamma CID 43– 537: (5)64; 2017
TEAM MEMBERS Andrea Kent Paul Bonnar Ian Davis
TEAM MEMBERS Jason Reynolds Stephen Smith Valerie Murphy Kim Abbass
VISION Safe and effective use of antimicrobial agents in patients cared for in NSHA
TENETS • Promote a culture of optimal antimicrobial use • Respect and promote regional strengths • Act in collaborative and engaging manner • Make evidence-based recommendations • Maintain an open/transparent program • Start small, build on success
Pharmacy Nursing Microbiology Clinicians Public IT
Antimicrobial Stewardship App The current application contains the following sections: Preamble: using antimicrobials responsibly Empiric guidelines for common infectious syndromes in pediatrics and women’s health with specific antimicrobial dosing for each syndrome. The guidelines represent consensus based on evidence-based guidelines and local microbiology and susceptibility patterns. to inform initial selection of empiric antimicrobial therapy, to optimize antimicrobial use and as such, provide better patient outcomes, including fewer adverse events and decrease in antimicrobial resistance related to antimicrobials. Antimicrobials : spectrum of activity, dosing for neonates, pediatrics and women’s health; information on drug monitoring, common usage, adverse effects, drug interactions and pharmacology Pathogens: information on precautions, local susceptibilities (linked to IWK Virtual Antibiogram), associated syndromes, epidemiology and other pathogen information IWK Virtual Antibiogram 2016: linked to the corresponding pathogens
WHY WE CARE Gould. J Antimicrob Chemother 2016; 71: 5
WHY WE CARE Canadian inpatients receiving Abx 2002 36. 5% P<0. 001 2009 Pipercillin-tazobactam as proportion of penicillin class 43% 20% P<0. 001 40. 1% 2002 >1 agent 38% Vancomycin Carbapenem 12% P<0. 001 2002 2009 Antifungal agents 2009 Taylor et al. Can J Infect Dis Med Microbiol 2015; 26(2): 85 -89
A Point Prevalence Survey of Antimicrobial Use at Hospitals in Nova Scotia Emily Black, Heather Neville, Mia Losier, Megan Harrison, Kim Abbass, Kathy Slayter, Lynn Johnston, and Ingrid Sketris 30% NS inpatients on antimicrobials Top Antimicrobial Agents Prescribed at Acute Care Hospitals in Nova Scotia (total prescribed antimicrobials, N = 660) 47% ICU Ampicillin 2. 0% Amoxicillin/Clavulanate 2. 0% Moxifloxacin 2. 1% Imipenem/Cilastatin 2. 6% Levofloxacin 3. 0% Fluconazole 3. 3% Sulfamethoxazole/Trimethoprim 3. 6% Cephalexin ~2/3 IV This study was funded by a grant from the Nova Scotia Health Research Foundation and the Faculty of Health Professions, Dalhousie University Do not cite or distribute 4. 4% Vancomycin (parenteral) 5. 5% Ciprofloxacin 7. 4% Piperacillin-tazobactam 8. 0% Ceftriaxone 8. 9% Cefazolin 10. 9% Metronidazole 0. 0% 11. 1% 2. 0% 4. 0% 6. 0% 8. 0% 10. 0% 12. 0% Black E, Neville H, Losier M, Harrison M, Abbass K, Slayter K, Johnston K, Sketris I. CPJ. 2017; 150(4): S 35. (abstract)
30% orders adherent to Handbook 60% NO documented duration of therapy
Holmes et al. Lancet 2016; 387: 176– 87
WHY WE CARE 27% patients received antibiotics 1 in 5 had antibioticassociated ADE n= 1488 Tamma. JAMA Intern Med. 2017 Jun 12
Core strategy Prospective audit and feedback Audit & feedback Tamma et al. 43– 537: (5)64; 2017
Other initiatives IV to PO policy Beta-lactam Allergy Antimicrobial Handbook Formulary Review Microbiology Initiatives
Antimicrobial Stewardship & Beta-lactam allergy
~10% US patients labelled as penicillin allergic • <10% of these patients have true allergy when tested • Penicillin anaphylaxis ~ 0. 01 -0. 05% • Ig. E allergy cephalosporins 0. 0001 -0. 1% https: //www. cdc. gov/getsmart/week/downloads/getsmart-penicillinfactsheet. pdf
Reasons for allergy label Viral rashes Family history Intolerances Recall
True allergy • Ig. E antibodies can decline and disappear with time • Decrease by approximately 10%/year • to approximately 30% after 10 years Yates. The American Journal of Medicine (2008) 121, 572 -576
Consequences LOS Tx failure Cost Beta-lactam allergy MDRO C diff
Cost • 15% documented allergy • 33% allergy description • Very few were anaphylaxis; most intolerances • 90% penicillin allergy • Mean cost higher in “allergic” • $26. 81 vs $16. 28; p=0. 004 Mac. Laughlin. Arch Fam Med. 2000; 9: 722 -726
Allergy is not benign • Allergy patients more: (p<. 0001) • Fluoroquinolones • Clindamycin • Vancomycin • More C. difficile: 23% (15. 6 -31. 7%) • MRSA 30% (12. 5 -50. 4%) • Increased LOS Macy. J Allergy Clin Immunol 2014; 133: 790 -6
EFFICACY – GNB BSI • 3 academic medial centers • Adult patients with a medical history of beta lactam allergy • Group that received beta-lactam did better • Failure 27. 4% vs 38. 7%; p=. 03 • Appropriate (mismatch sensi): 92% vs 75%; p<. 001 Jeffres. J Allergy Clin Immunol 2016; 137: 1148 -53
If I don’t use a beta-lactam: • Increased risk of • readmission for same infection • AKI • >50% non severe BL reaction • In group that did not receive beta-lactam • C diff • drug related sideeffects requiring discontinuation • Adj OR 3. 1 (1. 28 -7. 89) • No increase in adverse events Mac. Fadden. CID 10– 904: (7)63; 2016
Mac. Fadden. CID 10– 904: (7)63; 2016
https: //choosingwiselycanada. org/infectious-disease/
HOW TO TACKLE THE 10 -15% OF INPATIENTS REPORTING BLALLERGY
50% received BL at baseline; 60% by history; 81% BLAST The proportion of days of penicillin tripled (11% vs 32%; P <. 0002) Carbapenem & FQN use decreased by > ½ (28% vs 13%; P <. 0002)
Surgical Prophylaxis • 43% of allergic patients receive clindamycin • High rates of BL allergy
Beta-lactam allergy in surgery GENERAL SURGERY ORTHOPEDICS
Vancomycin for surgery • 2 tertiary Ontario hospitals • Random sample vancomycin prescriptions with chart review for two 12 -month periods • 51% used because of PCN allergy • Surgical prophylaxis: 66% (hosp A) and 58% (hosp B) of inappropriate prescriptions Kwan. Clin Invest Med 1999; 22(6): 256 -64
Making recommendations
Vancomycin for Surgery Dosing Efficacy Infusion time
Skin rash Hives Unknown anaphylaxis Cefazolin other Beltran et al. Journal of Pediatric Surgery 50 (2015) 856– 859
Skin rash 2% allergic reactions Hives Unknown anaphylaxis 1/127: hives+ erythema Cefazolin 15% other Beltran et al. Journal of Pediatric Surgery 50 (2015) 856– 859
T F A R D
Surgeons Nursing Anesthesia Pharmacy Preop OR
Who assess? Preop Anesthesia & Surgery How communicated? OR Outcomes Measure change
Beta lactam - summary • Allergy label is not benign • Correcting this label is not easy • Surgical prophylaxis is a starting point
THANK YOU ANDREA KENT andrea. kent@nsheatlh. ca PAUL BONNAR paule. bonnar@nshealth. ca http: //www. cdha. nshealth. ca/nshaantimicrobial-stewardship
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