Direct Challenges to Penicillin-Based Antibiotics in the Inpatient Setting.

BACKGROUND: Direct challenge (DC) is an emerging safe and effective alternative to penicillin skin testing (PST) in patients reporting a low-risk reaction history, but limited data exist for the inpatient setting. OBJECTIVE: To demonstrate the safety and efficacy of DC of penicillin-based antibiotics in the inpatient setting in patients with low-risk, cutaneous-only reaction histories more than 20 years ago. METHODS: Adult inpatients reporting penicillin allergy and receiving antibiotics were screened by an infectious disease PharmD for appropriateness for penicillin allergy delabeling. Patients with low-risk, cutaneous-only reaction histories (rash, hives, itching) more than 20 years ago were offered a 3-step DC. Patients with a cutaneous reaction history less than 20 years ago, a history of angioedema, or reactions involving multiple body systems underwent PST followed by a 1-time observed dose of amoxicillin. RESULTS: A total of 372 patients were screened during the study period, with 100 of these patients undergoing further evaluation, 52 with histories appropriate for PST and 48 with histories appropriate for DC. In the PST group, 44 of 52 (84.6%) patients were PST negative. In the DC group, 47 of 48 (97.9%) patients initially tolerated the DC, with 2 of 48 (4.2%) experiencing a delayed reaction. The sole patient with an immediate DC reaction was treated with an antihistamine alone. Beta-lactam antibiotics were subsequently used in 56 of the 100 total patients. Total direct antibiotic savings was $23,375.27. DC was less costly than PST, at $206.18/patient versus $419.63/patient. CONCLUSIONS: DC is a safe, effective, and less expensive method for penicillin delabeling in adult inpatients with a low-risk, cutaneous-only reaction history more than 20 years ago.

The Use of Telemedicine for Penicillin Allergy Skin Testing.

BACKGROUND: Penicillin skin testing (PST) is increasingly used as a tool to evaluate penicillin allergy in patients with a reported history. The limited availability of allergists, however, may be an impeding factor. OBJECTIVE: We sought to assess the clinical utility of telemedicine to facilitate PST. METHODS: Penicillin-allergic inpatients receiving systemic antibiotics were prospectively identified between April and August 2017. Qualifying patients underwent PST performed by a trained allergy/immunology physician assistant (PA). On completion of PST, a telemedicine consultation, through the use of real-time interactive video conferencing (Microsoft Lync 2013, Redmond, Wash), was performed remotely by an allergist. Patients were surveyed regarding their satisfaction with the telemedicine experience. RESULTS: Fifty patients consented to PST through a telemedicine consultation. The average total time to complete a consultation was 128 minutes (standard deviation [SD] ± 33). Of this, the average PA travel time was 46 minutes (36%) with the remaining time spent on clinical services (82 minutes, 64%). The average physician telemedicine time per patient was 5 minutes (SD ± 2). Patients rated their experience as an average of 4.5 on a scale of 1 (highly unsatisfied) to 5 (highly satisfied). Of the 46 PST-negative patients, 33 were transitioned to a ß-lactam antibiotic that reduced the use of vancomycin, metronidazole, aztreonam, aminoglycosides, and clindamycin (P < .05). More than $30,000 was saved throughout the study period. CONCLUSIONS: Telemedicine is an effective and novel approach to facilitate PST in the inpatient setting and carries a high degree of patient satisfaction. This method has the potential to optimize and improve access to allergy/immunology resources.