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Beta-lactam allergy labels and reduced first-line antibiotics for inpatient pneumonia

Published: May 21, 2021

Approximately 15% of hospitalized patients in the United States report an allergy to penicillin antibiotics, although up to 95% of these patients may be able to tolerate penicillin and other beta-lactam antibiotics. Beta-lactam antibiotics are generally considered more effective and less toxic than alternative antimicrobial agents for treatment across various infections, including pneumonia, which affects approximately 450 million people per year and a major cause of death across all age groups. In The Journal of Allergy and Clinical Immunology: In Practice, Mancini et al assess the association of a documented penicillin and/or cephalosporin allergy on inpatient antibiotic selection for the treatment of pneumonia in a large national cross-sectional sample of US hospitals.

This is a secondary analysis of inpatients with pneumonia at short-term acute care hospitals from a large national cross-sectional study of hospitalized patients within Vizient, a health care performance improvement company. The primary outcome was use of first-line beta-lactam antibiotics indicated for treatment of pneumonia in hospitalized patients, while the secondary outcomes considered antibiotic use by drug and drug class. These outcomes were examined by allergy status considering hospitalized patients with a history of penicillin and/or cephalosporin allergy and those without. Patient characteristics considered as potentially confounding factors included age, sex, race, inpatient location, hospital day number, medical comorbidities, resistant organism colonization or infection, and type of pneumonia.

Of 2,276 inpatients receiving antibiotics for treatment of pneumonia at 95 US hospitals, 450 (20%) had a documented penicillin and/or cephalosporin allergy and 1,826 (80%) did not have a documented penicillin or cephalosporin allergy. The majority of patients had low or medium risk allergy histories but 91 patients had high risk allergy histories. First-line indicated beta-lactam antibiotics were less frequently used in patients with a documented penicillin and/or cephalosporin allergy (44% vs 57%). Patients with a documented penicillin or cephalosporin allergy less frequently received penicillins (11% vs 33%), 3rd generation cephalosporins (18% vs 23%), and 4th generation cephalosporins (20% vs 13%). In the adjusted multivariable regression model, patients with a documented penicillin or cephalosporin allergy had a reduced prevalence of first-line indicated beta-lactam antibiotic use (adjusted prevalence ration 0.79) and increased prevalence of carbapenem (adjusted prevalence ratio 1.61) and/or fluoroquinolone (adjusted prevalence ratio 1.52) use. Considering the 91 patients with high-risk penicillin and/or cephalosporin allergies, adjusted prevalence of first-line indicated beta-lactams was even lower, and adjusted prevalence of carbapenem use was even higher, although adjusted prevalence of fluoroquinolone use was similar.

The Journal of Allergy and Clinical Immunology: In Practice is an official journal of the AAAAI, focusing on practical information for the practicing clinician.

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