Evaluation of Antibiotic Allergy in the Ambulatory Setting Using a Standardized Questionnaire.

Patients are sometimes mislabeled as having an immune-mediated antibiotic allergy in their medical records. Therefore, the aim of this study was to investigate the prevalence of subjects with non-immune mediated reactions to antibiotics using a standardized questionnaire. Subjects aged 18 years and older with a documented antibiotic allergy were identified and recruited from 2 outpatient clinics in the greater Chicago area. Subjects completed a standardized questionnaire during a single visit regarding their previous adverse reaction to an antibiotic. For subjects with multiple documented antibiotic allergies, 1 questionnaire was filled out for each antibiotic allergy. Investigators subsequently evaluated the questionnaire responses to determine whether the adverse reaction was a true immune-mediated allergic reaction or an adverse drug reaction. A total of 98 subjects were recruited with completion of 159 questionnaires. Eighteen subjects (18.37%, 95% CI: 10.7%, 26.3%) had antibiotic allergy labels with no corresponding immune-mediated reaction history. There were 35 allergy labels (22.0%, 95% CI: 14.7%, 29.4%) that were unlikely to be immune-mediated. Antibiotics with the highest percentage of clinical histories that were unlikely to be immune-mediated were macrolides (8 of 11 subjects), nitrofurantoin (1 of 2 subjects), and amoxicillin/clavulanate (2 of 8 subjects). The most common antibiotic allergy labels were penicillin (43 of 159 subjects), sulfonamides (25 of 159 subjects), and fluoroquinolones (21 of 159 subjects). Identification of adverse reactions to antibiotics that are unlikely to be immune-mediated can be accomplished using a standardized questionnaire in the outpatient setting. Improved identification of low-risk antibiotic allergy labels can guide de-labeling initiatives to improve antibiotic prescribing.

Introducing antimicrobial stewardship to the outpatient clinics of a suburban academic health system.

Objective: To establish an antimicrobial stewardship program in the outpatient setting. Design: Prescribers of antimicrobials were asked to complete a survey regarding antimicrobial stewardship. We also monitored their compliance with appropriate prescribing practices, which were shared in monthly quality improvement reports. Setting: The study was performed at Loyola University Health System, an academic teaching healthcare system in a metropolitan suburban environment. Participants: Prescribers of antimicrobials across 19 primary care and 3 immediate- and urgent-care clinics. Methods: The voluntary survey was developed using SurveyMonkeyand was distributed via e-mail. Data were collected anonymously. Rates of compliance with appropriate prescribing practices were abstracted from electronic health records and assessed by 3 metrics: (1) avoidance of antibiotics in adult acute bronchitis and appropriate antibiotic treatment in (2) patients tested for pharyngitis and (3) children with upper respiratory tract infections. Results: Prescribers were highly knowledgeable about what constitutes appropriate prescribing; verified compliance rates were highly concordant with self-reported rates. Nearly all prescribers were concerned about resistance, but fewer than half believed antibiotics were overprescribed in their office. Among respondents, 74% reported intense pressure from patients to prescribe antimicrobials inappropriately. Immediate- and urgent-care prescribers had higher rates of compliance than primary-care prescribers, and the latter group responded well to monthly reports and online educational resources. Conclusions: Intense pressure from patients to prescribe antimicrobials when they are not indicated leads to overprescribing, an effect compounded by the importance of patient satisfaction scores. Compliance reporting improved the number of appropriate antibiotics prescribed in the primary care setting.