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Pre-operative Recommendations for Patients with Beta-Lactam Allergy Labels · The SHEA Podcast

• 0:05
  SPEAKER_01: Welcome to the Updates from the SSI Compendium Podcast Series brought to you by the Society for Healthcare Epidemiology of America, SHA, promoting the prevention of healthcare associated infections and antibiotic resistance and seeking to advance the field of healthcare epidemiology and antibiotic stewardship.
• 0:20
  SPEAKER_01: I'm Dr.
• 0:21
  SPEAKER_01: Haley Pritchard, Assistant Professor of Clinical Medicine at Indiana University School of Medicine and Medical Director for Antimicrobial Stewardship at the Indiana University Health Adult Academic Medical Center, and I will serve as today's moderator.
• 0:33
  SPEAKER_01: Shea is excited to launch this episode of the updates from the SSI Compendium series entitled Preoperative Recommendations for Patients with Betalactum Alga Labels.
• 0:42
  SPEAKER_01: Today's discussion will address the preoperative interventions suggested in the SHAY SSI Compendium of Strategies update.
• 0:48
  SPEAKER_01: One area of focus will be on the role of beta-lactam allergy assessment for patients undergoing surgery as Vencomycin is no longer recommended for routine use.
• 0:55
  SPEAKER_01: We will also discuss how to educate both surgical and anesthesia providers and patients about the implications of beta-lactam allergy labels.
• 1:02
  SPEAKER_01: I'm happy to introduce our speakers for today.
• 1:04
  SPEAKER_01: First, we have Dr.
• 1:05
  SPEAKER_01: Kimberly Blumenthal.
• 1:06
  SPEAKER_01: Dr.
• 1:06
  SPEAKER_01: Blumenthal is an allergist, immunologist, and clinical researcher at Massachusetts General Hospital, who performs drug and vaccine allergy research that uses methods of epidemiology, informatics, economics, decision science, and implementation science.
• 1:19
  SPEAKER_01: Her research has been funded by the National Institute of Health, Agency for Healthcare Research and Quality, and foundations including the American Academy of Allergy, Asthma, and Immunology Foundation, and CRICO, the Risk Management Foundation of Harvard Medical School.
• 1:34
  SPEAKER_01: She is internationally recognized for identifying the morbidity and mortality associated with unverified penicillin allergies and creating innovative approaches to the evaluation of penicillin and cephalosporin antibiotic allergies in diverse patient settings.
• 1:46
  SPEAKER_01: Hi, I'm so happy to be here.
• 1:48
  SPEAKER_01: Next we have Dr.
• 1:49
  SPEAKER_01: Philip Lamb, infectious diseases specialist and assistant professor at the University of Toronto.
• 1:54
  SPEAKER_01: Dr.
• 1:54
  SPEAKER_01: Lamb is the medical director for the antimicrobial stewardship program at Sunnybrook Health Sciences Center, Toronto, Ontario, Canada.
• 2:00
  SPEAKER_01: His scholarly work is focused on using quality improvement methodology to develop sustainable system-level interventions to improve the appropriate use of antibiotics.
• 2:08
  SPEAKER_02: Hi, it's still here.
• 2:09
  SPEAKER_02: Thanks for inviting me.
• 2:10
  SPEAKER_01: Thank you all for joining us.
• 2:12
  SPEAKER_01: So let's jump in.
• 2:13
  SPEAKER_01: Our first question for today is how do beta lactam allergy labels impact antibiotic prescribing as a whole?
• 2:19
  SPEAKER_01: Dr.
• 2:19
  SPEAKER_01: Willenfall, would you like to comment?
• 2:21
  SPEAKER_00: Yes, absolutely.
• 2:22
  SPEAKER_00: So a penicillin allergy label or a reported or documented penicillin allergy is present in basically 5 to 10% of Americans.
• 2:33
  SPEAKER_00: And that prevalence increases the more our patients, you know, are in the healthcare system.
• 2:39
  SPEAKER_00: So if they're more sick, if they're inpatients, it's about 15%, and if they're cancer patients, about 20%.
• 2:45
  SPEAKER_00: And then cephalosporin allergy is also prevalent because we use cephalosporins a lot.
• 2:50
  SPEAKER_00: I always joke that the biggest risk factor for drug allergy is drug exposure.
• 2:56
  SPEAKER_00: So the cephalosporins are increasing in the allergy documentation prevalence somewhere around 2% to 4%.
• 3:03
  SPEAKER_00: And what we know is that even if all of these labels aren't real, even if all of these diagnoses aren't real, which we know that a lot of them aren't, many are disproved, the label itself impacts prescribing.
• 3:16
  SPEAKER_00: There are more quinolones, more macrolides, more clindamycin used in patients in usual care settings.
• 3:23
  SPEAKER_00: And then in the inpatient setting, it seems like as trionam is just still almost exclusively used in those with a penicillin allergy label.
• 3:31
  SPEAKER_00: And we know that what happens is that these changes in treatment just because of an allergy label is associated with an increased risk of treatment failures, adverse drug events, antibiotic resistance, and even all cause mortality.
• 3:45
  SPEAKER_00: Thank you so much.
• 3:46
  SPEAKER_00: Dr.
• 3:46
  SPEAKER_01: Lamb, do you have anything to add?
• 3:48
  SPEAKER_02: Yeah, I think the other thing to keep in mind is that when these adverse effects occur or toxicities occur, it also contributes to increased length of stay.
• 3:56
  SPEAKER_02: So significantly contributing to hospital costs in general.
• 4:00
  SPEAKER_02: We know that, you know, beta-lactam antibiotic classes are often first line for treatments of many infections, you know, things like staph aureus bacteremia, syphilis, or certain types of endocarditis.
• 4:12
  SPEAKER_02: And so complete avoidance of this class and using these alternate agents really puts patients at risk of significant adverse effects.
• 4:19
  SPEAKER_01: Thank you so much.
• 4:20
  SPEAKER_01: Dr.
• 4:20
  SPEAKER_01: Lamb, how do you think that the updated recommendation against the routine use of vencomycin for SSI prevention will affect practices for patients with beta lactam allergy labels?
• 4:29
  SPEAKER_02: So, first off, I'm very glad to see that statement in this update.
• 4:33
  SPEAKER_02: As you know, vencomycin is fraught with many issues, particularly in the perioper setting.
• 4:38
  SPEAKER_02: It needs to be administered over an infusion over an hour, which oftentimes complicates the timing of the incision.
• 4:45
  SPEAKER_02: And many times the dose is given too soon, right before incision, and you're not really getting adequate levels.
• 4:52
  SPEAKER_02: You also run into a lot of issues with nephrotoxicity, and that's been shown in a number of studies looking at vancomycin use and SSI.
• 4:58
  SPEAKER_02: So the hope is that recommending against use of vancomycin will hopefully encourage prescribers to really think about these betalactam allergy labels and to explore interventions, ways that we can help to clarify these allergies and promote the use of betalactam first-line agents.
• 5:15
  SPEAKER_01: Awesome.
• 5:16
  SPEAKER_01: Dr.
• 5:16
  SPEAKER_01: Blumenthal, anything to add to that?
• 5:18
  SPEAKER_00: Yeah, I think that that's a great point and really interesting when we both have done sort of similar studies where you're looking at prophylaxis and you're looking at beta-lactam, surgical prophylaxis versus vancomycin.
• 5:31
  SPEAKER_00: And one of the things we kept thinking is we were maybe just looking at beta-lactam prophylaxis versus no prophylaxis because of how hard it is to dose uh appropriately.
• 5:40
  SPEAKER_00: I think that in general, even though the beta-lactams are our most common drug allergy cause that we know of, its side effect profile and its tendency to cause allergies still less than bankomycin.
• 5:52
  SPEAKER_00: So I was very happy to see the guidance change and also just the encouragement to take an allergy history more than just confirming what's there, to take an allergy history because of the increased risk of SSI in patients who have a reported but unproven beta-lactam allergy history.
• 6:12
  SPEAKER_01: So, kind of adding to the emphasis on taking an allergy history, which I think is also an amazing recommendation.
• 6:19
  SPEAKER_01: I think a lot of institutions are trying to improve how we assess allergies and teach our learners to assess allergies.
• 6:24
  SPEAKER_01: So, tying into that, what are some strategies for preoperative care providers to identify patients who can safely receive beta lactams without a formal allergy referral?
• 6:32
  SPEAKER_01: Dr.
• 6:32
  SPEAKER_01: Blumenthal.
• 6:33
  SPEAKER_00: I would definitely always start with this really low-hanging fruit, which is that most of the things documented in our electronic health record allergy section is not allergic reactions.
• 6:45
  SPEAKER_00: There are headaches, fatigue, GI upset, itching.
• 6:49
  SPEAKER_00: There are many things where there is no real concern for a true allergic reaction.
• 6:54
  SPEAKER_00: And for any of those side effect or intolerance reactions, we could even have a discussion with patients about just immediate removal of that allergy.
• 7:02
  SPEAKER_00: And then they could have any beta lactam, whether it's in a surgical environment or a non-surgical environment in follow-up.
• 7:08
  SPEAKER_00: I think that formal allergy referral is now really only necessary for those who are the highest risk allergic patients, patients who have multiple drug allergies, multiple antibiotic allergies, or a history of anaphylaxis or angiodema, epinephrine use, or recent or current reactions.
• 7:25
  SPEAKER_00: Those are the patients who should see somebody before you go and prescribe first-line beta-lactam surgical site infection prophylaxis.
• 7:33
  SPEAKER_00: But beyond that, there are many, many patients who have intolerances or side effects or who have low risk reactions.
• 7:40
  SPEAKER_00: And it's to penicillin and a very long time ago.
• 7:43
  SPEAKER_00: And we'd have very little to no concern about using beta-lactam prophylaxis, particularly if we're talking about cephalin or encephrophylaxis, because if we remember the uh chemical structure of cephalin or ANCF is unique and it does have a beta-lactam ring, so their cross-tractivity is theoretically possible, but the real genesis of the allergy is this our group, this side chain group, and it's different from all of the penicillins and the cephalosporins.
• 8:14
  SPEAKER_00: And so we have a lot of confidence that this specific cephalosporin is tolerated in almost all patients with a penicillin allergy.
• 8:20
  SPEAKER_00: Thank you so much.
• 8:21
  SPEAKER_00: Dr.
• 8:21
  SPEAKER_00: Lamb, anything to add?
• 8:23
  SPEAKER_02: Yeah, I think it's a great point about the cross-reactivity between penicillin and cephazolin.
• 8:28
  SPEAKER_02: And I think that's a very unique situation in perioperative medicine where cephasilin is considered, you know, the first line agent for most surgical procedures.
• 8:36
  SPEAKER_02: And so a lot of the allergy assessment can actually be standardized into quite a simplified algorithm to identify these patients that are very low risk of number one, having an appendicillin allergy to begin with, and number two, the ones that actually would cross-react with cephasin, which is essentially none if patients are reporting appendicillin allergy.
• 8:57
  SPEAKER_02: And I think a lot of the challenge amongst uh perioperative healthcare providers is they may not feel confident about making these assessments.
• 9:05
  SPEAKER_02: And I think there's a lot of opportunity out there to standardize and create pathways, you know, identify specific questions that patients should be asked to help really nail down that risk of having a true allergy.
• 9:17
  SPEAKER_02: There have been a number of excellent publications in the past year looking at validated scoring systems to identify these patients who are very low risk.
• 9:25
  SPEAKER_02: You may have heard of the Pen Fast tool that was recently kind of described and really showing that you can easily identify patients at low risk of having true penicillin allergy without actually doing skin testing.
• 9:36
  SPEAKER_01: Thank you.
• 9:37
  SPEAKER_01: My next question is what words of advice do you have for antibiotic stewards or infection registrants who are trying to implement these big lactam allergy assessment policies and recommendations at their institution to get buy-in from other stakeholders like surgeons, anesthesiologists, and the pre- and perioperative testing clinics?
• 9:58
  SPEAKER_01: Dr.
• 9:59
  SPEAKER_01: Lamb?
• 9:59
  SPEAKER_02: Yeah, it's a great question.
• 10:00
  SPEAKER_02: I think that's one of the big challenges when we're trying to roll out something as big as this practice change.
• 10:06
  SPEAKER_02: I think one of the important things that other non-allergists slash ID physicians may not appreciate are the potential harms of prescribing vancomycin or clindamycin as the alternate SSI prophylaxis agent.
• 10:19
  SPEAKER_02: I don't think many prescribers realize that there is an increased risk of surgical site infection when alternate agents are used.
• 10:26
  SPEAKER_02: And secondly, I don't think others may appreciate this, again, lack of cross-reactivity between penicillin and cephalin, in that even patients with true penicillin allergy, they can still safely receive cephalin.
• 10:37
  SPEAKER_02: So I think that's number one, just raising awareness of the potential harms of not providing, you know, the best agent for surgical prophylaxis.
• 10:46
  SPEAKER_02: I think the second thing is showing that, you know, an assessment for allergy and the determination of the best surgical prophylaxis can actually be quite simple.
• 10:53
  SPEAKER_02: It doesn't need to be a very complex algorithm, particularly when we're talking about choosing cephasolin as our surgical prophylaxis.
• 11:00
  SPEAKER_02: It can be as simple as a couple of questions just to understand is this patient reported a severe cutaneous adverse reaction, what was the offending agent, and just you know what the reaction was in general.
• 11:10
  SPEAKER_02: I think with those three questions, you can actually implement such an algorithm to be you know easily implemented into a workflow.
• 11:17
  SPEAKER_00: Thank you.
• 11:18
  SPEAKER_00: And Dr.
• 11:18
  SPEAKER_00: Blumenthal, it's a really good idea to think about the perioperative space almost separately from what we do in the outpatient and inpatient because of the focus on the ANSEF and cephalin.
• 11:30
  SPEAKER_00: And you really can make a very easy user-friendly way of just knowing who's safe for it and who isn't.
• 11:38
  SPEAKER_00: I completely agree.
• 11:39
  SPEAKER_00: If there's no immediate reaction that's high risk and there's no severe cutaneous reaction, like usually I screen for did you have to be hospitalized in a burn unit or have mucosal lesions or any organ involvement?
• 11:50
  SPEAKER_00: So those sort of two main questions can get you to a place where you feel very comfortable prescribing cephalin.
• 11:58
  SPEAKER_00: Now, I think that it just really should be at a policy level, a hospital or health system level, because they're all of the FDA labels still report cross-reactivity between penicillins and cephalosporins generally, and even for the package insert of our FDA labels for cephalin, we'll say this.
• 12:14
  SPEAKER_00: It is very challenging for individuals to prescribe when they're worried about potentially medical legal consequences or you know, the first do no harm, but not only realizing that first do no harm means actually, in this case, getting them cephasolin, but the hospitals and healthcare systems can help with an infrastructure or guidance so that this is what the hospital says we do in this situation, then the individual clinicians will just feel more comfortable following that guidance.
• 12:42
  SPEAKER_00: In general, I think that our prescribing is very diffuse.
• 12:46
  SPEAKER_00: I don't know whether it's the same everywhere, but when we came out with these data from our own institutions and these were 9,000 surgeries of our own institution, let me show you your SSI rate and your use of cephalin and penicillin allergy to make changes to the prescribing.
• 13:00
  SPEAKER_00: Sometimes was meeting with the nurses who ran the pre-op anesthesia clinic, sometimes was meeting with individual surgeons, like for example, the cardiothoracic surgeons that work with us directly.
• 13:12
  SPEAKER_00: And it was really confusing to see who prescribes it, who chooses the antibiotics.
• 13:16
  SPEAKER_00: So I think for the infection preventionists and antibiotic stewardship folks thinking about implementation, it's certainly just thinking about if there's just one decision maker or many other decision makers that have to be involved.
• 13:29
  SPEAKER_00: Um, we're still working years later on getting everybody to do the same thing.
• 13:33
  SPEAKER_00: But certainly a pre-op clinic for at least the elective surgeries, I think, would be the ideal place to have this history tool that is used.
• 13:42
  SPEAKER_00: And if you happen to have the bandwidth, maybe uh delabel the patient too.
• 13:47
  SPEAKER_00: So if you think that they're low risk or no risk for being truly penicillin allergic, potentially that pre-op clinic, if it happens in person, could actually delabel the patient.
• 13:57
  SPEAKER_00: That way you remove any chance that they would not get cephalin on surgery day, and also their future healthcare also could benefit from whatever antibiotics are needed.
• 14:08
  SPEAKER_02: One of the strategies that we used at our institution was actually empowering the anesthesiologist to really take ownership of deciding what perioperative antibody to administer.
• 14:18
  SPEAKER_02: After all, they're the ones who will deal with the consequence if someone truly does have a reaction, you know, in the OR.
• 14:24
  SPEAKER_02: They are a much smaller group in our hospital, maybe 40 of them, as opposed to hundreds of surgeons.
• 14:29
  SPEAKER_02: And so when we talk about variability in practice, if you're able to let the anesthesiologist take ownership, they're a much smaller group.
• 14:35
  SPEAKER_02: And you're able to achieve a more consistent practice pattern by kind of empowering them.
• 14:41
  SPEAKER_02: And so we've kind of let them take the lead on this, and the surgeons know to defer to them, you know, when these more challenging kind of allergy cases come up.
• 14:49
  SPEAKER_01: That sounds like a great avenue to simplify the process of who to who to talk to, who to get buy-in from, than trying to go to every every single subspecialty that may or may not be involved.
• 14:58
  SPEAKER_01: For our final question of uh of the program, how would you recommend educating patients with allergy labels about the safety of using big lactams for SSI prophylaxis?
• 15:07
  SPEAKER_01: Uh, Dr.
• 15:07
  SPEAKER_01: Bubenthal.
• 15:08
  SPEAKER_00: Well, I suppose in a resource unlimited world where I would think that every single patient who had a surgery planned would probably benefit from some interaction just specifically about their allergy.
• 15:22
  SPEAKER_00: It's just a good touch point when you think about the natural history of patients with have penicillin allergy labels often placed in childhood.
• 15:30
  SPEAKER_00: They stay there for a really long time until they cause problems.
• 15:33
  SPEAKER_00: And maybe a surgery is like just a almost a pivotal point in that you could say this is a good touch point to address these allergies.
• 15:43
  SPEAKER_00: So I certainly, and part of my practice is seeing pre-operative patients in my allergy specialist practice.
• 15:50
  SPEAKER_00: So if there were, you know, clones of meat everywhere, we would be able to do this so that we all had going into a surgery know if patients are allergic to penicillin or not.
• 16:00
  SPEAKER_00: Sometimes there are other allergy labels there too that might interfere with surgery, even things like NSIDs and opiates or latex.
• 16:07
  SPEAKER_00: So I think that there is a still a role for the allergist sometimes pre-operatively.
• 16:12
  SPEAKER_00: And in those settings, we're able to sort of talk to patients more about what is an allergy, because this is also the problem of labeling, is that everything is self-reported and put into the record, and we are able to explain the natural history.
• 16:28
  SPEAKER_00: So if that can't happen, then I think that what we need is very sort of short educational tools that can be used by anesthesia nurses or um pre-op nurses, anesthesiologists to give out, or the surgical NPs have been useful allies for us, where we just give a one-sheet page to patients about why they're being asked about their allergy.
• 16:48
  SPEAKER_00: A lot of preoperative patients have a long laundry list of things to do before their operation, especially my my cardiac patients who, you know, they have so many things to do.
• 16:57
  SPEAKER_00: We just added talk about your allergies to that list and information that they receive.
• 17:02
  SPEAKER_00: So I think also letting people know that FDA labels, people who do read the labels of things and and they always say that things can cause rashes and and um that they shouldn't take it if they're allergic to something else.
• 17:13
  SPEAKER_00: We have a problem with dispensing, even um, you know, in our pharmacies, things that might be cross-reactive.
• 17:20
  SPEAKER_00: So I think I've always tell patients that just because you were allergic to penicillin doesn't mean that you're always gonna be allergic to penicillin, and in fact, it goes away over time, not like peanut allergy and not like allergy to your cat, but allergy to penicillin goes away over time.
• 17:34
  SPEAKER_00: And then I also explain that the antibiotics that are often wanting to give during surgery have a very low likelihood of causing a problem and have a high likelihood of doing the job of preventing an infection.
• 17:47
  SPEAKER_00: Awesome.
• 17:48
  SPEAKER_00: And Dr.
• 17:48
  SPEAKER_00: Lamb.
• 17:49
  SPEAKER_02: Yeah, I think those are great points.
• 17:50
  SPEAKER_02: I think it's so important that patients understand the whole idea of having a beta lactam allergy label and why we are wanting to give things like cephazolin, really, to minimize the risk of any surgical side infection from happening.
• 18:05
  SPEAKER_02: Because if they don't understand why you've delabeled them or what you've prescribed for them, this allergy label may perpetuate in another healthcare setting in the future, particularly if you don't have a shared electronic medical system where you know the allergy label can be appended or updated.
• 18:19
  SPEAKER_02: Patients who don't understand their allergy and it's been delabeled may still think they have one and tell another healthcare provider in the future that they have one.
• 18:26
  SPEAKER_02: And again, that just kind of resets everything and makes it more challenging in the future to really convince them otherwise.
• 18:31
  SPEAKER_02: So it's so important for them to understand why it's important that we kind of delabel patients.
• 18:37
  SPEAKER_02: Um, and as Dr.
• 18:38
  SPEAKER_02: Blumenthal mentioned, that not all allergies are forever and that people can outgrow allergies.
• 18:43
  SPEAKER_01: Awesome.
• 18:44
  SPEAKER_01: Well, thank you so much for a fantastic conversation and for providing so much information and practical tools for stewards and infection preventionists who are looking to expand this at their own institutions.
• 18:55
  SPEAKER_01: We appreciate you joining us so much today.
• 18:57
  SPEAKER_00: If you have any last words for the viewers, feel free.
• 19:01
  SPEAKER_00: Just wanted to say thank you for having me today.
• 19:04
  SPEAKER_00: And I am so excited to continue to work with the antibiotic stewards and infection preventionists.
• 19:10
  SPEAKER_00: My colleagues in ID have been fantastic partners in the antibiotic allergy problem as well as the solutions.
• 19:18
  SPEAKER_00: So thank you and thanks for having me.
• 19:20
  SPEAKER_02: Thanks so much for having me.
• 19:22
  SPEAKER_02: I think it's it's been an excellent few years collaborating with allergists, anesthesiologists, surgeons on trying to improve uh prophylactic use of cephazolin and beta lactans.
• 19:32
  SPEAKER_02: I think there's still a lot of work to be done, and you know, this can be really applied to so many other aspects of patient care.
• 19:39
  SPEAKER_02: So thanks again.
• 19:40
  SPEAKER_01: Thank you both.
• 19:41
  SPEAKER_01: You can find more educational content like this podcast on Shay's Online Education Center, Learning CE, at www.learningce.shay online.org.
• 19:52
  SPEAKER_01: This concludes today's episode of the updates from the SSI Compendium podcast, and thank you for tuning in.