Student Summer Scholar Final Report
Fifteen percent of hospitalized patients have a documented penicillin (PCN) allergy. However, fewer than one percent of those patients have a true IgE-mediated reaction that necessitates avoidance of beta-lactam antibiotics.Labeling a patient with a PCN allergy is associated with prescribing non-beta-lactam (NBL) broad spectrum antibiotics and increased adverse outcomes. Patients with a documented PCN allergy have 23% more Clostridium difficile infections, and a documented PCN allergy costs 600 dollars more per inpatient infection. Education-only interventions to address overuse of NBLs have rarely resulted in sustained change. The aim of this project was to reduce the use of unnecessary NBL in patients with a PCN allergy through a two-pronged quality intervention project.
The four-month intervention took place between June 2021-Sept 2021. The target population was prescribers (attendings, residents, nurse practitioners, and physician assistants) on the internal medicine service at an 1100 bed urban hospital. The intervention included an educational and electronic medical record (EMR) component. The educational component included virtual lectures on antibiotic prescribing best practices paired with a weekly in-person marketing campaign in June and July. The EMR component included adding a link to antibiotic prescribing best practices directly in the EMR allergy history record and developing a novel best practice alert (BPA) to notify the clinician if a patient with a PCN allergy had received a beta-lactam in the past. Pre and post intervention data were compared using chi-squared tests.
Data showed a significant, sustained increase in the percent of beta-lactams prescribed for patients with a PCN allergy who had “other” or “unknown” as a reaction type (pre-intervention: 19%; post intervention: 28%, p-value = 0.026). In addition, the data showed a statistically significant increase in the percent of beta-lactams prescribed to patients with a PCN allergy who have a documented low severity reaction (pre-intervention: 20%; post intervention: 26%; p-value = 0.043). These changes could reflect enhanced antibiotic stewardship for patients with low-risk PCN allergies. The intervention also showed a significant increase in the percent of allergy histories updated (pre-intervention: 90% to post-intervention 100%, p-value: <0.0001). This reflected a key component of the educational intervention that emphasized the importance of documenting a robust allergy history with an accurate reaction type. Numbers for both of these metrics showed a slight decrease over time once the intensive in-person marketing campaign subsided, but maintained a significant change throughout the four-month intervention.
The beta-lactam history BPA included one NBL only, Aztreonam, for the pilot. The goal was to prove the safety of the BPA due to concerns of clinicians choosing an antibiotic that would trigger an allergic reaction. The BPA fired ten times over the four-month intervention. No adverse events were triggered by the BPA (no orders of epinephrine or ‘anaphylaxis order set’); highlighting the safety of the BPA. The BPA will need to be expanded to include additional non-beta-lactam broad spectrum antibiotics in order to determine the effectiveness in changing orders to a more appropriate antibiotic.
The intervention was effective for patients with a PCN allergy with a reaction type of “other” and “unknown” but not for antibiotic prescriptions overall. Future expansion of the beta-lactam history BPA to include additional NBLs will allow evaluation of the effectiveness in changing antibiotic orders to beta-lactams for low-risk PCN allergy patients. We plan to expand the BPA to include additional NBLs to better evaluate the effectiveness in helping clinicians evaluate appropriate antibiotics for patients with PCN allergies and a positive history of beta lactam administration.
Bryana Banashefski, MD candidate Class of 2024, Icahn School of Medicine at Mount Sinai
Surafel Tsega, MD, Mount Sinai Hospital
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