The Role of Clinical Pharmacists in Patients with Suspected Allergy to β-Lactams: A Systematic Review
Journal: Advances in Medicine and Engineering Interdisciplinary Research DOI: 10.32629/ameir.v2i3.2268
Abstract
Objective: To analyze the role played by the clinical pharmacist and its impact in antibiotic stewardship facing suspected allergy to beta-lactam antibiotics. Method: We performed 2 different independent bibliographic searches. A total of 35 articles were found, and the final number included in the study was 12. We analyzed the articles and collected variables of efficacy, safety, and applicability of evaluation tools applied to patients with suspected allergy to beta-lactams. Also, the variation in the consumption and prescription profile of alternative antibiotics was analyzed. Results: The selected studies analyzed questionnaires, allergy delabeling, intradermal tests, and oral challenge tests performed by pharmacists. Significant differences in the efficacy endpoint were found in 4 studies in favor of pharmaceutical intervention. In the study of Kwiatkowski et al., cefazolin use increased in surgical patients after pharmacist intervention (28% vs 65%; P < 0 .01). In a quasi-experimental study, the mean defined daily dose of aztreonam and the mean days of therapy per 1,000 patients/day decreased (21.23 vs 9.05, P < 0.01) and (8.79-4.24, P = 0.016), pre- and post-intervention, respectively, increasing antibiotic de-escalations (P < 0.01). In another quasi-experimental study, the prescription of restricted use antibiotics decreased (42.5% vs 17.9%, P < 0 .01) and the use of pre-surgical prophylactic antibiotics alternative to cefazolin (81.9% vs 55.9%, P < 0.01) in another study. Other study showed that the mean time per interview was 5.2 min per patient. No adverse events were reported in any study. Conclusion: The pharmacist intervention in the evaluation of the patient with suspected allergy to beta-lactams is effective, safe, and feasible to implement on daily clinical practice. The standardization of protocols to clarify the history of allergies and development of evaluation tools represents simple screenings to perform delabeling or refer to the immunoallergology service, improving penicilin use and reducing the need for second-line antibiotics. More studies are needed to standardize the desensitization tests made by pharmacists. However, despite these results, the involvement and leadership of the pharmacist in this area is limited and constitutes a future challenge for the profession.
Keywords
beta-lactams (β-Lactams); allergy; antibiotic stewardship; antibiotic administration; pharmacist; pharmacy
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[27] Song YC, Nelson ZJ, Wankum MA, Gens KD. Effectiveness and feasibility of pharmacist-driven penicillin allergy de-labeling pilot program without skin testing or oral challenges. Pharmacy (Basel). 2021;9:127. doi: 10.3390/pharmacy9030127
[28] Despacho n.° 10901/2022 - Diário da República n.° 174/2022, Série II de 2022-09-08. Accessed 04/07/2023. Available from: https://dre.pt/DRE_Trad/DescontinuacaoIE. Aspx
[29] Trubiano JA, Vogrin S, Chua KYL, Bourke J, Yun J, Douglas A, et al. Development and validation of a penicillin allergy clinical decision rule. JAMA Intern Med. 2020;180:745-52. doi: 10.1001/jamainternmed.2020.0403
[30] Powell N, Stephens J, Kohl D, Owens R, Ahmed S, Musicha C, et al. The effectiveness of interventions that support penicillin allergy assessment and de-labelling of adult and paediatric patients by non-allergy specialists: a systematic review and meta-analysis. Int J Infect Dis. 2023;129:152-61. doi: 10.1016/j.ijid.2022.11.026
[31] Mabilat C, Gros M-F, Van Belkum A, Trubiano JA, Blumenthal KG, Romano A, et al. Improving antimicrobial stewardship with penicillin allergy testing: a review of current practices and unmet needs. JAC Antimicrob Resist. 2022;4:dlac116. doi: 10.1093/ jacamr/dlac116
[2] Shenoy ES, Macy E, Rowe T, Blumenthal KG. Evaluation and management of penicillin allergy: a review. JAMA. 2019;15(321):188-99. doi: 10.1001/jama.2018.19283
[3] Bhogal R, Hussain A, Balaji A, Bermingham WH, Marriott JF, Krishna MT. The role of a clinical pharmacist in spurious Penicillin allergy: a narrative review. Int J Clin Pharm. 2021;43:461-75. doi: 10.1007/s11096-020-01226-7
[4] Blanca M, Romano A, Torres MJ, Férnandez J, Mayorga C, Rodriguez J, et al. Update on the evaluation of hypersensitivity reactions to betalactams. Allergy. 2009;64:183-93. doi: 10.1111/j.1398-9995.2008.01916.x
[5] Laxminarayan R. The overlooked pandemic of antimicrobial resistance. Lancet. 2022;399:606-7. doi: 10.1016/S0140-6736(22)00087-3
[6] WHO Regional Office for Europe/European Centre for Disease Prevention and Control. Antimicrobial resistance surveillance in Europe 2022-2020 data. Copenhagen: WHO Regional Office for Europe; 2022.
[7] Rodríguez-Baño J, Paño-Pardo JR, Alvarez-Rocha L, Asensio A, Calbo E, Cercenado E, et al. Programas de optimización de uso de antimicrobianos (PROA) en hospitales españoles: documento de consenso GEIH-SEIMC, SEFH y SEMPSPH. Enferm Infecc Microbiol Clin. 2012;30:22.e1-22.e23. doi: 10.1016/j.eimc.2011.09.018
[8] European Centre for Disease Prevention and Control. Proposals for EU guidelines on the prudent use of antimicrobials in humans. Stockholm. Available from: http://ecdc.europa.eu/en/publications/Publications/EU-guidelinesprudent-use-antimicrobials.pdf.
[9] Goff DA, Karam GH, Haines ST. Impact of a national antimicrobial stewardship mentoring program: insights and lessons learned. Am J Health Syst Pharm. 2017;74:224-31. doi: 10.2146/ajhp160379
[10] Nault V, Pepin J, Beaudoin M, Perron J, Moutquin JM, Valiquette L. Sustained impact of a computer-assisted antimicrobial stewardship intervention on antimicrobial use and length of stay. J Antimicrob Chemother. 2017;72:933-40. doi: 10.1093/jac/dkw468
[11] Kokta N. Antimicrobial stewardship: how the community pharmacist can help. Inside Pharmacy. 2017:5 Accessed 04/07/2023. Available from: http://www. insidepatientcare.com/issues/2017/january-2017-vol-5-no-1/452-antimicrobialstewardship-how-the-community-pharmacist-can-help
[12] ASHP statement on the pharmacist's role in antimicrobial stewardship and infection prevention and control. Am J Health Syst Pharm. 2010;67:575-7. doi: 10.2146/ sp100001
[13] Barlam TF, Cosgrove SE, Abbo LM, MacDougall C, Schuetz AN, Septimus EJ. Implementing an antibiotic stewardship program: guidelines by the infectious diseases Society of America and the society for healthcare epidemiology of America. Clin Infect Dis. 2016;62:e51-77. doi: 10.1093/cid/ciw118
[14] Page MJ, McKenzie JE, Bossuyt PM, Boutron I, Hoffmann T, Mulrow C, et al. The PRISMA 2020 statement: an updated guideline for reporting systematic reviews. J Clin Epidemiol. 2021;134:178-89. doi: 10.1016/j.jclinepi.2021.03.001
[15] Demoly P, Kropf R, Bircher A, Pichler WJ. Drug hypersensitivity: questionnaire. EAACI interest group on drug hypersensitivity. Allergy. 1999;54:999-1003. doi: 10.1034/ j.1398-9995.1999.00247.x
[16] du Plessis T, Walls G, Jordan A, Holland DJ. Implementation of a pharmacist-led penicillin allergy de-labelling service in a public hospital. J Antimicrob Chemother. 2019;74:1438-46. doi: 10.1093/jac/dky575
[17] Mitchell AB, Ness RA, Bennett JG, Bowden JE, Elliott WV, Gillion AR, et al. Implementation and impact of a β-lactam allergy assessment protocol in a veteran population. Fed Pract. 2021;38:420-5. doi: 10.12788/fp.0172
[18] Harmon S, Richardson T, Simons H, Monforte S, Fanning S, Harrington K. The clinical and financial impact of a pharmacist-driven penicillin skin testing program on antimicrobial stewardship practices. Hosp Pharm. 2020;55:58-63. doi: 10.1177/ 0018578718817917
[19] Turner NA, Wrenn R, Sarubbi C, Kleris R, Lugar P, Radojicic C, et al. Evaluation of a pharmacist-led penicillin allergy assessment program and allergy delabeling in a tertiary care hospital. JAMA Netw Open. 2021;4, e219820. doi: 10.1001/jamanetworkopen.2021.9820
[20] Mann KL, Wu JY, Shah SS. Implementation of a pharmacist-driven detailed penicillin allergy interview. Ann Pharmacother. 2020;54:364-70. doi: 10.1177/1060028019884874
[21] Clark KE, Briand ME, Kapoor O, Pirasteh A. Impact of a standardized beta-lactam allergy questionnaire on aztreonam use. J Pharm Pract. 2019;32:399-403. doi: 10.1177/0897190018758557
[22] Devchand M, Kirkpatrick CMJ, Stevenson W, Garrett K, Perera D, Khumra S, et al. Evaluation of a pharmacist-led penicillin allergy de-labelling ward round: a novel antimicrobial stewardship intervention. J Antimicrob Chemother. 2019;74:1725-30. doi: 10.1093/jac/dkz082
[23] Vaisman A, McCready J, Hicks S, Powis J. Optimizing preoperative prophylaxis in patients with reported β-lactam allergy: a novel extension of antimicrobial stewardship. J Antimicrob Chemother. 2017;72:2657-60. doi: 10.1093/jac/dkx171
[24] Ham Y, Sukerman ES, Lewis 2nd JS, Tucker KJ, Yu DL, Joshi SR. Safety and efficacy of direct two-step penicillin challenges with an inpatient pharmacist-driven allergy evaluation. Allergy Asthma Proc. 2021;42:153-9. doi: 10.2500/aap.2021.42.200128
[25] Louden NJ, Hansen LA, Rimal A, Norton LE. Implementation of a pharmacist-driven penicillin and cephalosporin allergy assessment tool: a pilot evaluation. J Pediatr Pharmacol Ther. 2021;26:696-701. doi: 10.5863/1551-6776-26.7.696
[26] Kwiatkowski S, Mulugeta S, Davis S, Kenney R, Kalus J, Walton L, et al. Optimizing preoperative antibiotics in patients with β-lactam allergies: a role for pharmacy. Am J Health Syst Pharm. 2021;78(Supplement_3):S76-82. doi: 10.1093/ajhp/ zxab218
[27] Song YC, Nelson ZJ, Wankum MA, Gens KD. Effectiveness and feasibility of pharmacist-driven penicillin allergy de-labeling pilot program without skin testing or oral challenges. Pharmacy (Basel). 2021;9:127. doi: 10.3390/pharmacy9030127
[28] Despacho n.° 10901/2022 - Diário da República n.° 174/2022, Série II de 2022-09-08. Accessed 04/07/2023. Available from: https://dre.pt/DRE_Trad/DescontinuacaoIE. Aspx
[29] Trubiano JA, Vogrin S, Chua KYL, Bourke J, Yun J, Douglas A, et al. Development and validation of a penicillin allergy clinical decision rule. JAMA Intern Med. 2020;180:745-52. doi: 10.1001/jamainternmed.2020.0403
[30] Powell N, Stephens J, Kohl D, Owens R, Ahmed S, Musicha C, et al. The effectiveness of interventions that support penicillin allergy assessment and de-labelling of adult and paediatric patients by non-allergy specialists: a systematic review and meta-analysis. Int J Infect Dis. 2023;129:152-61. doi: 10.1016/j.ijid.2022.11.026
[31] Mabilat C, Gros M-F, Van Belkum A, Trubiano JA, Blumenthal KG, Romano A, et al. Improving antimicrobial stewardship with penicillin allergy testing: a review of current practices and unmet needs. JAC Antimicrob Resist. 2022;4:dlac116. doi: 10.1093/ jacamr/dlac116
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