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Improving inpatient paediatric de-labelling of allergies to beta-lactams: a quality improvement study
  1. Jacqueline Wong1,2,3,
  2. Adelle Atkinson4,5,
  3. Kathryn Timberlake6,
  4. Carolyn E Beck5,7,
  5. Bryan Maguire8,
  6. Michelle Science3,5
  1. 1Division of Infectious Diseases, McMaster Children's Hospital, Hamilton, Ontario, Canada
  2. 2Department of Pediatrics, Faculty of Health Sciences, McMaster University, Hamilton, Ontario, Canada
  3. 3Division of Infectious Diseases, The Hospital for Sick Children, Toronto, Ontario, Canada
  4. 4Division of Immunology and Allergy, The Hospital for Sick Children, Toronto, Ontario, Canada
  5. 5Department of Paediatrics, Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
  6. 6Department of Pharmacy, The Hospital for Sick Children, Toronto, Ontario, Canada
  7. 7Division of Paediatric Medicine, The Hospital for Sick Children, Toronto, Ontario, Canada
  8. 8The Hospital for Sick Children, Toronto, Ontario, Canada
  1. Correspondence to Dr Jacqueline Wong, Division of Infectious Diseases, Department of Pediatrics, McMaster University, Hamilton, Canada; wongj37{at}mcmaster.ca

Abstract

Objective To evaluate the implementation of an antimicrobial stewardship programme-led inpatient beta-lactam allergy de-labelling programme using a direct oral provocation test (OPT).

Design One-year quality improvement study using a before–after design.

Setting Free-standing tertiary care paediatric hospital.

Patients Patients with a reported beta-lactam allergy admitted to the paediatric medicine inpatient unit.

Interventions Following standardised assessment and risk stratification of reported symptoms, patients with a low-risk history were offered an OPT. Beta-lactam allergy labels were removed if a reported history was considered non-allergic or after successful OPT.

Main outcome measures Removal of inappropriate beta-lactam allergy labels.

Results 80 patients with 85 reported beta-lactam allergies were assessed. Median age was 8.1 years (IQR 4.8–12.9) and 34 (42%) were female. The majority (n=55, 69%) had an underlying medical condition. Amoxicillin was the most reported allergy (n=25, 29%). Reported reactions were primarily dermatological (n=65, 77%). Half of participants (n=40) were ineligible for OPT, with equal proportions due to clinical reasons or the nature of the reported reaction. Of the 40 eligible patients, 28 patients (70%) were de-labelled either by history alone (n=10) or OPT (n=18). All OPTs were successful. De-labelling allowed five additional patients (11% of those receiving antibiotics) to receive the preferred beta-lactam. Including patients who were subsequently assessed in the allergy clinic, almost half of all evaluated patients were de-labelled (n=37, 46%).

Conclusions An antimicrobial stewardship programme-led programme using a direct OPT was feasible and safe for expanding beta-lactam allergy de-labelling to paediatric patients admitted to the paediatric medicine inpatient unit.

  • Paediatrics
  • Allergy and Immunology
  • Infectious Disease Medicine

Data availability statement

Data are available upon reasonable request. Deidentified participant data that underlie the results will be available following publication. Researchers who provide a scientifically sound proposal will be allowed access to the aggregate participant data. Proposals should be directed to michelle.science@sickkids.ca or wongj37@mcmaster.ca. These proposals will be reviewed and approved by the investigator and collaborators on the basis of scientific merit.

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Data availability statement

Data are available upon reasonable request. Deidentified participant data that underlie the results will be available following publication. Researchers who provide a scientifically sound proposal will be allowed access to the aggregate participant data. Proposals should be directed to michelle.science@sickkids.ca or wongj37@mcmaster.ca. These proposals will be reviewed and approved by the investigator and collaborators on the basis of scientific merit.

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Footnotes

  • X @JWong_PedsID, @AtkinsonAdelle, @KatTPharmD

  • Presented at Preliminary data from this work were presented in part at the 56th Annual Meeting of the Infectious Diseases Society of America (IDWeek); 4 October 2018; San Francisco, California, USA; Abstract 269 (Wong J, Timberlake K, Atkinson A, Science M. 269. De-Labeling of Allergies to B-Lactam Antibiotics (De-LABeL) Program: Development and Pilot of an INpatient Pediatric Program. Open Forum Infectious Diseases. 2018;5(suppl_1):S112-S). It was also presented in part at the 9th Annual International Pediatric Antimicrobial Stewardship Conference (31 May 2018; St Louis, Missouri, USA).

  • Contributors JW, MS, AA and KT conceived of and conceptualised the study design. JW contributed to data curation, assisted with the formal analysis, prepared the data visualisations and wrote the original draft. CEB contributed to the conceptualisation of the study design. BM conducted the formal analysis. MS contributed to the study investigation, provided overall supervision for the study, and is the guarantor for this study. All authors reviewed and edited the final manuscript, revised it critically for important intellectual content and gave approval for final submission.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests None declared.

  • Provenance and peer review Not commissioned; internally peer reviewed.

  • Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.