title: Impact of a clinical guideline for prescribing antibiotics to inpatients reporting penicillin or cephalosporin allergy.
abstract: BACKGROUND
  Self-reported penicillin allergy infrequently reflects an inability to tolerate penicillins. Inpatients reporting penicillin allergy receive alternative antibiotics that might be broader spectrum, more toxic, or less effective.
  
  
  OBJECTIVE
  To develop and assess a clinical guideline for the general inpatient provider that directs taking a history and prescribing antibiotics for patients with penicillin or cephalosporin allergy.
  
  
  METHODS
  A guideline was implemented to assist providers with assessing allergy history and prescribing antibiotics for patients with reported penicillin or cephalosporin allergy. The guideline used a standard 2-step graded challenge or test dose. A quasi-experimental study was performed to assess safety, feasibility, and impact on antibiotic use by comparing treatment 21 months before guideline implementation with 12 months after guideline implementation.
  
  
  RESULTS
  Significantly more test doses to β-lactam antibiotics were performed monthly after vs before guideline implementation (median 14.5, interquartile range 13-16.25, vs 2, interquartile range 1-3.25, P < .001). Seven adverse drug reactions occurred during guideline-driven test doses, with no significant difference in rate (3.9% vs 6.1%, P = .44) or severity (P > .5) between periods. Guideline-driven test doses decreased alternative antimicrobial therapy after the test dose, including vancomycin (68.3% vs 37.2%, P < .001), aztreonam (11.5% vs 0.5%, P < .001), aminoglycosides (6.0% vs 1.1%, P = .004), and fluoro quinolones (15.3% vs 3.3%, P < .001).
  
  
  CONCLUSIONS
  The implementation of an inpatient antibiotic prescribing guideline for patients with penicillin or cephalosporin allergy was associated with an almost 7-fold increase in the number of test doses to β-lactams without increased adverse drug reactions. Patients assessed with guideline-driven test doses were observed to have significantly decreased alternative antibiotic exposure.
authors.affiliation: Division of Rheumatology, Allergy, and Immunology, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts; Medical Practice Evaluation Center, Massachusetts General Hospital, Boston, Massachusetts; Harvard Medical School, Boston, Massachusetts. Electronic address: kblumenthal1@partners.org.
authors.forename: Kimberly G
authors.initials: KG
authors.lastname: Blumenthal
authors.affiliation: Medical Practice Evaluation Center, Massachusetts General Hospital, Boston, Massachusetts; Harvard Medical School, Boston, Massachusetts; Division of Infectious Diseases, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts; Infection Control Unit, Massachusetts General Hospital, Boston, Massachusetts.
authors.forename: Erica S
authors.initials: ES
authors.lastname: Shenoy
authors.affiliation: Division of Infectious Diseases, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts; Department of Pharmacy, Massachusetts General Hospital, Boston, Massachusetts.
authors.forename: Christy A
authors.initials: CA
authors.lastname: Varughese
authors.affiliation: Harvard Medical School, Boston, Massachusetts; Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts.
authors.forename: Shelley
authors.initials: S
authors.lastname: Hurwitz
authors.affiliation: Harvard Medical School, Boston, Massachusetts; Division of Infectious Diseases, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts; Infection Control Unit, Massachusetts General Hospital, Boston, Massachusetts.
authors.forename: David C
authors.initials: DC
authors.lastname: Hooper
authors.affiliation: Division of Rheumatology, Allergy, and Immunology, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts; Harvard Medical School, Boston, Massachusetts.
authors.forename: Aleena
authors.initials: A
authors.lastname: Banerji
mesh_terms: D000900:Anti-Bacterial Agents / Q000009:adverse effects* / Q000627:therapeutic use; D002511:Cephalosporins / Q000008:administration & dosage / Q000009:adverse effects*; D004342:Drug Hypersensitivity / Q000453:epidemiology* / Q000209:etiology; D011307:Drug Prescriptions / Q000592:standards*; D005260:Female; D006801:Humans; D007297:Inpatients; D008297:Male; D008875:Middle Aged; D010406:Penicillins / Q000008:administration & dosage / Q000009:adverse effects*; D017410:Practice Guidelines as Topic / Q000592:standards*; D010818:Practice Patterns, Physicians'; D057566:Self Report; D012882:Skin Tests
chemical_list: D000900:Anti-Bacterial Agents; D002511:Cephalosporins; D010406:Penicillins