Hostname: page-component-8448b6f56d-c47g7 Total loading time: 0 Render date: 2024-04-24T12:51:59.859Z Has data issue: false hasContentIssue false
  • English
  • Français

Anatomy of a successful stewardship intervention: Improving perioperative prescribing in penicillin-allergic patients

Published online by Cambridge University Press:  16 August 2021

Mary Elizabeth Sexton Open the ORCID record for Mary Elizabeth Sexton [Opens in a new window] ,
Merin Elizabeth Kuruvilla ,
Francis A. Wolf ,
Grant C. Lynde  and
Zanthia Wiley
Mary Elizabeth Sexton*
Affiliation:
Division of Infectious Diseases, Emory University School of Medicine, Atlanta, Georgia
Merin Elizabeth Kuruvilla
Affiliation:
Division of Pulmonary, Allergy, Critical Care and Sleep Medicine, Emory University School of Medicine, Atlanta, Georgia
Francis A. Wolf
Affiliation:
Department of Anesthesiology, Emory University School of Medicine, Atlanta, Georgia
Grant C. Lynde
Affiliation:
Department of Anesthesiology, Emory University School of Medicine, Atlanta, Georgia
Zanthia Wiley
Affiliation:
Division of Infectious Diseases, Emory University School of Medicine, Atlanta, Georgia
*
Author for correspondence: Mary Elizabeth Sexton, E-mail: marybeth.sexton@emory.edu
Get access Rights & Permissions [Opens in a new window]

Abstract

Objective:

To evaluate whether a series of quality improvement interventions to promote safe perioperative use of cephalosporins in penicillin-allergic patients improved use of first-line antibiotics and decreased costs.

Design:

Before-and-after trial following several educational interventions.

Setting:

Academic medical center.

Patients:

This study included patients undergoing a surgical procedure involving receipt of a perioperative antibiotic other than a penicillin or carbapenem between January 1, 2017, and August 31, 2019. Patients with and without a penicillin allergy label in their electronic medical record were compared with respect to the percentage who received a cephalosporin and average antibiotic cost per patient.

Methods:

A multidisciplinary team from infectious diseases, allergy, anesthesiology, surgery, and pharmacy surveyed anesthesiology providers about their use of perioperative cephalosporins in penicillin-allergic patients. Using findings from that survey, the team designed a decision-support algorithm for safe utilization and provided 2 educational forums to introduce this algorithm, emphasizing the safety of cefazolin or cefuroxime in penicillin-allergic patients without history of a severe delayed hypersensitivity reaction.

Results:

The percentage of penicillin-allergic patients receiving a perioperative cephalosporin improved from ∼34% to >80% following algorithm implementation and the associated educational interventions. This increase in cephalosporin use was associated with a ∼50% reduction in antibiotic cost per penicillin-allergic patient. No significant adverse reactions were reported.

Conclusions:

An educational antibiotic stewardship intervention produced a significant change in clinician behavior. A simple intervention can have a significant impact, although further study is needed regarding whether this response is sustained and whether an educational intervention is similarly effective in other healthcare systems.

Type
Original Article
Information
Infection Control & Hospital Epidemiology , Volume 43 , Issue 9 , September 2022 , pp. 1101 - 1107
Check for updates
Copyright
© The Author(s), 2021. Published by Cambridge University Press on behalf of The Society for Healthcare Epidemiology of America

Access options

Get access to the full version of this content by using one of the access options below. (Log in options will check for institutional or personal access. Content may require purchase if you do not have access.)

Footnotes

PREVIOUS PRESENTATION. Preliminary data from this study were presented as an oral abstract at the SHEA conference in Boston, Massachusetts on April 26, 2019.

References

Bratzler, DW, Dellinger, EP, Olsen, KM, et al. Clinical practice guidelines for antimicrobial prophylaxis in surgery. Surg Infect (Larchmt) 2013;14:73–156.CrossRefGoogle ScholarPubMed
Blumenthal, KG, Lu, N, Zhang, Y, Li, Y, Walensky, RP, Choi, HK. Risk of meticillin resistant Staphylococcus aureus and Clostridium difficile in patients with a documented penicillin allergy: population based matched cohort study. BMJ 2018;361:k2400.CrossRefGoogle ScholarPubMed
Blumenthal, KG, Ryan, EE, Li, Y, Lee, H, Kuhlen, JL, Shenoy, ES. The impact of a reported penicillin allergy on surgical site infection risk. Clin Infect Dis 2018;66:329–336.CrossRefGoogle ScholarPubMed
Robertsson, O, Thompson, O, A WD, Sundberg M, Lidgren L, Stefansdottir A. Higher risk of revision for infection using systemic clindamycin prophylaxis than with cloxacillin. Acta Orthop 2017;88:562–567.CrossRefGoogle Scholar
Bull, AL, Worth, LJ, Richards, MJ. Impact of vancomycin surgical antibiotic prophylaxis on the development of methicillin-sensitive Staphylococcus aureus surgical site infections: report from Australian Surveillance Data (VICNISS). Ann Surg 2012;256:1089–1092.CrossRefGoogle Scholar
Murphy, J, Isaiah, A, Dyalram, D, Lubek, JE. Surgical site infections in patients receiving osteomyocutaneous free flaps to the head and neck. does choice of antibiotic prophylaxis matter? J Oral Maxillofac Surg 2017;75:2223–2229.CrossRefGoogle Scholar
Uppal, S, Harris, J, Al-Niaimi, A, et al. Prophylactic antibiotic choice and risk of surgical site infection after hysterectomy. Obstet Gynecol 2016;127:321–329.CrossRefGoogle ScholarPubMed
Strymish, JM, W OB, Itani K, Gupta K, Branch-Elliman W. What is the primary driver of preoperative vancomycin use? It’s not MRSA or allergy. Clin Infect Dis 2020;71:2732–2735.CrossRefGoogle ScholarPubMed
Zagursky, RJ, Pichichero, ME. Cross-reactivity in beta-Lactam Allergy. J Allergy Clin Immunol Pract 2018;6:72–81 e71.CrossRefGoogle ScholarPubMed
Kuruvilla, M, Shih, J, Patel, K, Scanlon, N. Direct oral amoxicillin challenge without preliminary skin testing in adult patients with allergy and at low risk with reported penicillin allergy. Allergy Asthma Proc 2019;40:57–61.CrossRefGoogle ScholarPubMed
Kuruvilla, M, Sexton, M, Wiley, Z, Langfitt, T, Lynde, GC, Wolf, F. A streamlined approach to optimize perioperative antibiotic prophylaxis in the setting of penicillin allergy labels. J Allergy Clin Immunol Pract 2020;8:1316–1322.CrossRefGoogle ScholarPubMed
Romano, A, Valluzzi, RL, Caruso, C, Zaffiro, A, Quaratino, D, Gaeta, F. Tolerability of Cefazolin and Ceftibuten in Patients with IgE-Mediated Aminopenicillin Allergy. J Allergy Clin Immunol Pract 2020;8:1989–1993.CrossRefGoogle ScholarPubMed
Picard, M, Robitaille, G, Karam, F, et al. Cross-reactivity to cephalosporins and carbapenems in penicillin-allergic patients: two systematic reviews and meta-analyses. J Allergy Clin Immunol Pract 2019;7:2722–2738.CrossRefGoogle ScholarPubMed
Fan, B, Udeh, B, Quinn, N, Bernard, SL, Grobmyer, SR, Valente, SA. Delabeling penicillin allergy in breast surgery patients: a cost analysis. Am Surg 2020;86:e75–e78.CrossRefGoogle ScholarPubMed
Molina, J, Penalva, G, Gil-Navarro, MV, et al. Long-term impact of an educational antimicrobial stewardship program on hospital-acquired candidemia and multidrug-resistant bloodstream infections: a quasi-experimental study of interrupted time-series analysis. Clin Infect Dis 2017;65:1992–1999.CrossRefGoogle ScholarPubMed
Goff, DA, Kullar, R, Bauer, KA, File, TM Jr. Eight habits of highly effective antimicrobial stewardship programs to meet the joint commission standards for hospitals. Clin Infect Dis 2017;64:1134–1139.CrossRefGoogle ScholarPubMed
Chang, YY, Chen, HP, Lin, CW, et al. Implementation and outcomes of an antimicrobial stewardship program: effectiveness of education. J Chin Med Assoc 2017;80:353–359.CrossRefGoogle ScholarPubMed
Barlam, TF, Cosgrove, SE, Abbo, LM, et al. 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–e77.CrossRefGoogle Scholar
Meeker, D, Linder, JA, Fox, CR, et al. Effect of behavioral interventions on inappropriate antibiotic prescribing among primary care practices: a randomized clinical trial. JAMA 2016;315:562–570.CrossRefGoogle ScholarPubMed
Roque, F, Herdeiro, MT, Soares, S, Teixeira Rodrigues, A, Breitenfeld, L, Figueiras, A. Educational interventions to improve prescription and dispensing of antibiotics: a systematic review. BMC Public Health 2014;14:1276.CrossRefGoogle ScholarPubMed
Knox, MC, Edye, M. Educational antimicrobial stewardship intervention ineffective in changing surgical prophylactic antibiotic prescribing. Surg Infect (Larchmt) 2016;17:224–228.CrossRefGoogle ScholarPubMed
Powell, BJ, Waltz, TJ, Chinman, MJ, et al. A refined compilation of implementation strategies: results from the Expert Recommendations for Implementing Change (ERIC) project. Implement Sci 2015;10:21.CrossRefGoogle ScholarPubMed
Lam, PW, Tarighi, P, Elligsen, M, et al. Impact of Allergy Clarification for Cefazolin Evidence-based Prescribing Tool (ACCEPT) on receipt of preferred perioperative prophylaxis: an interrupted time series study. Clin Infect Dis 2020;71:2955–2957.CrossRefGoogle Scholar
Trubiano, JA, Chua, KYL, Holmes, NE, et al. Safety of cephalosporins in penicillin class severe delayed hypersensitivity reactions. J Allergy Clin Immunol Pract 2020;8:1142–1146.CrossRefGoogle ScholarPubMed