MSQC – ASPIRE Collaborative

Meeting

4/21/23

Rajan Ravikumar MD

Clinical Assistant Professor

Division of Allergy and Clinical Immunology

Michigan Medicine

Disclosure

• None

True Beta-Lactam Allergy is uncommon…

• 10-15% of patients in the United States report a beta-lactam allergy

• >90% patients who report a beta-lactam allergy are not allergic

True Beta-Lactam reactions often wane over time

• PCN - 50% - 5 years, 80% - 10 years

• Ceph – 60-70% - 5 years

Romano et al. Allergy 2014

Impact of beta-lactam allergy label

Vancomycin Levofloxacin

39.7

21.5

17.4

PCN allergy

Lee CE. Arch Inter Med. 2000.

↑ 23%

C. diff

↑ 30%

VRE

↑ 69%

MRSA

Macy E. JACI 2014

Blumenthal. BMJ 2018

Blumenthal. CID Feb 2018; 66

Surgical Prophylaxis

• MGH: 8385 patients

– PCN allergy associated with

SSI on MV model (OR

1.51;

95% CI 1.02- 2.22)

• UM Colorectal: 9,949 patients

– Prophylaxis with non-beta-

lactam associated with SSIs

(OR

1.65; 1.20- 2.26)

• Sunnybrook Toronto: 3,589 pts

– BL allergy associated with

SSIs (OR

1.61; 1.04- 2.51).

100

Cefaz Clinda Vanco Gent FQ

PCN allergy

• Alternatives also suboptimal:

• Longer infusion

(vanco/quinolones)

• More toxic (vanco/gent)

Blumenthal Clin Infect Dis 2018; Kuriakose JP J Am Coll Surg 2019; Lam PW Infect Control Hosp Epidemiol 2020.

Risk-Benefit

• Historical View:

Benefits of BL use:

• Improved empiric coverage

• Decreased toxicity/collateral

damage

• Improved outcomes (SSIs,

mortality, etc.)

Risk of

reaction

Low Risk of

reaction

• Updated View:

Michigan Medicine

Initiatives

• Empiric Therapy Guidance

• In-patient Service (BLAES)

• Out-pt referrals

Empiric Therapy Guidance

• Bottom line: almost all patients with penicillin allergies, including

anaphylaxis, can safely receive cephalosporin-based pre-operative

surgical prophylaxis with recommended agents such as cefazolin. This

will avoid less efficacious/more toxic therapies like clindamycin,

aminoglycosides, and vancomycin.

1. Khan DA et al. J Allergy Clin Immunol 2022. 2. https://www.med.umich.edu/asp/pdf/adult_guidelines/Beta-lactam-Evaluation-and-Empiric.pdf

Remove Beta-Lactam Allergy Warnings

• Kaiser Permanente Southern California - Removed the warning

• Kaiser Permanente Northern California - Retained the warning

Macy JAMA Network Open 2021

47% Cephalosporins

Beta-Lactam Allergy Evaluation Service (BLAES)

• Two 1.2FTE NP’s – July 2021 to Present

• Inpatient Adult, Peds, OB/Gyn patients

• Mon-Fri 8-5pm

Step 1

Patient

admitted

Step 2

Consult order

placed

Step 3

Medication

History Review

Step 4

Bedside history

and Risk

Stratification

Step 5

1. Evaluation

and De-labeling

2. Education

Step 6

Communication

and Follow up

Step 7

Active monitoring

of relabels and

removing labels

again if erroneous

Primary

Team or ID

pharmacy

Michigan Medicine Experience

BLAES service >800 labels removed or updated

• >98% drug challenges were negative (only 2 needed epinephrine)

• >30% by Medication History Review

• >50% - Low Risk - Drug challenge without prior penicillin skin testing

• <6% of patients experienced relabeling of their beta-lactam allergy

Out-patient dedicated Beta-Lactam appts and consult order

• Reduced avg. wait time for appt from >3 months to under 3 weeks.

Removed the beta-lactam warning label for low-risk patients

THANK YOU

Team Members:

• Rajan Ravikumar MD – Allergy

• Lauren Barhitte FNP and Becka

Ha ns on FNP – BLAES

• Teja l Ga ndhi MD – Infectious Disease

•

Greg Eschenauer PharmD,

Samuel Aitken Pharm D, and

Jerod Nagel Pharm D –

Antim icrob ia l

Stewardship Pharmacy

• Nonie Arora MD – Internal Medicine

• Vin c e Ma r s h a ll MS – Clinical Pharmacy

• Ka tie Ba rw ig, RN – CNO Admin

• Linda Bashaw – HITS

• Sheri Penar – HITS

• Matt Enell, PharmD – HITS

• Liz Spranger – Internal Medicine Quality