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Guideline improves test doses in patients with penicillin and cephalosporin allergy

An antibiotic prescription guideline increased test doses without increasing adverse drug reactions in patients with penicillin and cephalosporin allergy at Massachusetts General Hospital, according to study results.

“Test doses after implementation helped improve antimicrobial management, resulting in less vancomycin, aminoglycoside, aztreonam and fluoroquinolone use,” Kimberly G. Blumenthal, MD, of the department of medicine at Massachusetts General Hospital, and colleagues wrote.

Kimberly G. Blumenthal

Blumenthal and colleagues developed and tested a clinical guideline for the general inpatient provider that directs taking a history and prescribing antibiotics for patients with penicillin or cephalosporin allergy.

Prior to the guideline being implemented in April 2013, allergy and immunology (AI) department consultation was required for all tests doses at the hospital.

After implementation, test doses of B-lactam antibiotics did not require consultation.

The researchers conducted a quasi-experimental study to evaluate the hospital-wide clinical guideline 21 months before implementation and 12 months after implementation.

Before guideline implementation, the researchers identified 49 test doses of B-lactam antibiotics with a median of two test doses per month. The researchers identified 183 test doses with a median of 14.5 tests per month after guideline implementation.

Before the guideline, patients received the test a median of 4 days into hospitalization. The median number of days dropped to 2 after implementation.

The researchers noted no difference in adverse drug reaction (ADR) rate before (4%) and after (6%) guideline implementation.

Test doses after guideline implementation resulted in more patients on various penicillins (19% vs. 2%, P < .001) and cephalosporins of the first (10% vs. 0.6%, P < .001), third (30% vs. 5%, P < .001) and fourth (32% vs. 7%, P < .001) generations.

Blumenthal and colleagues wrote of the possible expenses that could have been saved using the implemented guidelines including costs associated with length of stay and test administration.

“Because the guideline ADR rate was similar to the rate in the AI literature after skin testing, implementation of the guideline could have saved 164 inpatient penicillin skin tests without incurring any additional costs,” the researchers wrote. “The cost of 164 skin tests performed by AI, using Medicare reimbursement, would total approximately $60,000 in 2014.”

Disclosure: The researchers report no relevant financial disclosures.