title: Tackling inpatient penicillin allergies: Assessing tools for antimicrobial stewardship.
abstract: BACKGROUND
  Reported penicillin allergy rarely reflects penicillin intolerance. Failure to address inpatient penicillin allergies results in more broad-spectrum antibiotic use, treatment failures, and adverse drug events.
  
  
  OBJECTIVE
  We aimed to determine the optimal approach to penicillin allergies among medical inpatients.
  
  
  METHODS
  We evaluated internal medicine inpatients reporting penicillin allergy in 3 periods: (1) standard of care (SOC), (2) penicillin skin testing (ST), and (3) computerized guideline application with decision support (APP). The primary outcome was use of a penicillin or cephalosporin, comparing interventions to SOC using multivariable logistic regression.
  
  
  RESULTS
  There were 625 patients: SOC, 148; ST, 278; and APP, 199. Of 278 ST patients, 179 (64%) were skin test eligible; 43 (24%) received testing and none were allergic. In the APP period, there were 292 unique Web site views; 112 users (38%) completed clinical decision support. Although ST period patients did not have increased odds of penicillin or cephalosporin use overall (adjusted odds ratio [aOR] 1.3; 95% CI, 0.8-2.0), we observed significant increased odds of penicillin or cephalosporin use overall in the APP period (aOR, 1.8; 95% CI, 1.1-2.9) and in a per-protocol analysis of the skin tested subset (aOR, 5.7; 95% CI, 2.6-12.5).
  
  
  CONCLUSIONS
  Both APP and ST-when completed-increased the use of penicillin and cephalosporin antibiotics among inpatients reporting penicillin allergy. While the skin tested subset showed an almost 6-fold impact, the computerized guideline significantly increased penicillin or cephalosporin use overall nearly 2-fold and was readily implemented.
authors.affiliation: Division of Rheumatology, Allergy, and Immunology, Department of Medicine, Massachusetts General Hospital, Boston, Mass; Medical Practice Evaluation Center, Massachusetts General Hospital, Boston, Mass; Edward P. Lawrence Center for Quality and Safety, Massachusetts General Hospital and the Massachusetts General Professional Organization, Boston, Mass; Harvard Medical School, Boston, Mass. Electronic address: kblumenthal1@partners.org.
authors.forename: Kimberly G
authors.initials: KG
authors.lastname: Blumenthal
authors.affiliation: Harvard Medical School, Boston, Mass; Division of Rheumatology, Allergy, and Immunology, Department of Medicine, Brigham and Women's Hospital, Boston, Mass.
authors.forename: Paige G
authors.initials: PG
authors.lastname: Wickner
authors.affiliation: Harvard Medical School, Boston, Mass; Department of Medicine, Brigham and Women's Hospital, Boston, Mass.
authors.forename: Shelley
authors.initials: S
authors.lastname: Hurwitz
authors.affiliation: University of Minnesota Medical School, Minneapolis, Minn.
authors.forename: Nicholas
authors.initials: N
authors.lastname: Pricco
authors.affiliation: New York Medical College, Valhalla, NY.
authors.forename: Alexandra E
authors.initials: AE
authors.lastname: Nee
authors.affiliation: Harvard Medical School, Boston, Mass; Department of Medicine, Brigham and Women's Hospital, Boston, Mass.
authors.forename: Karl
authors.initials: K
authors.lastname: Laskowski
authors.affiliation: Medical Practice Evaluation Center, Massachusetts General Hospital, Boston, Mass; Harvard Medical School, Boston, Mass; Division of Infectious Disease, Department of Medicine, Massachusetts General Hospital, Boston, Mass; Infection Control Unit, Massachusetts General Hospital, Boston, Mass.
authors.forename: Erica S
authors.initials: ES
authors.lastname: Shenoy
authors.affiliation: Medical Practice Evaluation Center, Massachusetts General Hospital, Boston, Mass; Harvard Medical School, Boston, Mass; Division of Infectious Disease, Department of Medicine, Massachusetts General Hospital, Boston, Mass.
authors.forename: Rochelle P
authors.initials: RP
authors.lastname: Walensky
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D000900:Anti-Bacterial Agents / Q000009:adverse effects* / Q000627:therapeutic use; D002511:Cephalosporins / Q000009:adverse effects / Q000627:therapeutic use; D003661:Decision Support Techniques; D004342:Drug Hypersensitivity / Q000175:diagnosis* / Q000517:prevention & control; D004363:Drug Utilization; D005260:Female; D006801:Humans; D007297:Inpatients; D008297:Male; D008875:Middle Aged; D010406:Penicillins / Q000009:adverse effects* / Q000627:therapeutic use; D017410:Practice Guidelines as Topic; D012882:Skin Tests; D059039:Standard of Care
chemical_list: D000900:Anti-Bacterial Agents; D002511:Cephalosporins; D010406:Penicillins
keywords: Stewardship; computerized guideline; decision support; skin test; test dose