Low frequency of allergy referral for penicillin allergy evaluation in an urban Boston primary care setting.

Background: A key strategy to combat the public health crisis of antimicrobial resistance is to use appropriate antibiotics, which is difficult in patients with a penicillin allergy label. Objective: Our aim was to investigate racial and ethnic differences related to penicillin allergy labeling and referral to allergy/immunology in primary care. Methods: This was a retrospective study of Tufts Medical Center's Boston-based primary care patients in 2019. Univariable and multivariable logistic regression models were used to examine demographic associations with (1) penicillin allergy label and (2) allergist referral. Results: Of 21,918 primary care patients, 2,391 (11%) had a penicillin allergy label; of these, 249 (10%) had an allergist referral. In multivariable logistic regression models, older age (adjusted odds ratio [aOR] = 1.06 [95% CI = 1.04-1.09]) and female sex (aOR = 1.58 [95% CI = 1.44-1.74]) were associated with higher odds of penicillin allergy label carriage. Black race (aOR = 0.77 [95% CI = 0.69-0.87]) and Asian race (aOR = 0.47 [95% CI = 0.41-0.53]) were associated with lower odds of penicillin allergy label carriage. In multivariable regression, allergist referral was associated with female sex (aOR = 1.52 [95% CI = 1.10-2.10]) and Black race (aOR = 1.74 [95% CI = 1.25-2.45]). Of 93 patients (37%) who completed their allergy visit, 26 (28%) had received penicillin allergy evaluation or were scheduled to receive a penicillin allergy evaluation at a future visit. Conclusions: There were racial differences in penicillin allergy labeling and referral. Allergy referral for penicillin allergy assessment was rare. Larger studies are needed to assess penicillin allergy labeling and delabeling with an equity focus on optimizing patient health outcomes.

Implementation of the Surviving Sepsis Campaign in Patients With Heart Failure: Gender-Specific Outcomes.

Background Limited data exist about the impact of gender-specific outcomes in patients with heart failure (HF) who develop concomitant sepsis. Methods This is a retrospective cohort study of patients with HF who developed sepsis. Clinical outcomes, including in-hospital mortality, development of cardiogenic shock (CS), pulmonary edema requiring urgent intravenous diuretics (IVD), acute kidney injury (AKI), length of stay (LOS), and 30-day HF-related readmission, were evaluated in men vs. women. Results This cohort of 618 patients includes 272 (44%) women with a mean age of 75±14 years. Coronary artery disease (p<0.0001), diabetes mellitus (p=0.0213), stage ≥ 3 chronic kidney disease (p<0.0001), and HF with reduced ejection fraction (HFrEF) (p=0.0015) were more prevalent in men. The implementation of the Surviving Sepsis Campaign (i.e., intravenous (IV) crystalloids in the first six hours) was more aggressive in women (p=0.0192). There was no difference in in-hospital mortality (p=0.2385) between men and women. After adjusting for HF types, women with HF with preserved ejection fraction (HFpEF) developed more episodes of pulmonary edema requiring urgent IVD (p=0.0389), while men with HFpEF had more CS requiring inotropes (p=0.0400) and a longer LOS (p=0.0434). Conversely, women with HFrEF were most likely to develop CS requiring inotropes (p=0.0132). Conclusion Women with HF who developed sepsis receive a more aggressive implementation of the Surviving Sepsis Campaign than men, leading to more pulmonary edema events in women with HFpEF and more cardiogenic shock in women with HFrEF. A cautiously tailored approach is desperately needed for patients with HF who develop sepsis.

The Effect of Hydroxychloroquine on In-Hospital Mortality in COVID-19.

Background: Hydroxychloroquine (HCQ) is an antimalarial medication that has been tested against various viral illnesses. The available evidence regarding the role of HCQ in the coronavirus disease 2019 (COVID-19) remains controversial. Methods: This is a comparative retrospective cohort study that aims to evaluate the efficacy and safety of HCQ in hospitalized patients with COVID-19. The primary outcome was all-cause in-hospital mortality. Secondary outcomes included ICU admission rate, mechanical ventilation, prolonged length of stay (LOS), QTc prolongation and cardiac arrest. Results: A cohort of 175 hospitalized patients with COVID-19 were included with a median (interquartile range [IQR]) age of 66 [48-79] years. Of whom, 82 (47%) patients received HCQ. The overall mortality rate was 34.1%; 95% CI [23.7-44.6] and 16.1%; 95% CI [8.5-23.7] in the HCQ group vs. the control group, respectively (p = 0.67). A Cox regression analysis was performed adjusting for age, gender, BMI, SpO2/FiO2 ratio and CXR findings, and demonstrated that the association between HCQ use and the all-cause in-hospital mortality was not statistically significant (HR = 1.15; 95% CI [0.54-2.48]; p-value = 0.72). Patients who received HCQ were more likely to be admitted to the intensive care unit, require mechanical ventilation and have a prolonged LOS compared to those who did not receive the medication. No statistically significant difference was found in the likelihood of QTc prolongation or cardiac arrest. Conclusions: The use of HCQ in patients hospitalized with COVID-19 confers no benefit in patient morbidity or mortality.