Risk assessment options – part 2

In this step, you will continue to learn about the risk assessment tools used in various settings. Two of our educators discuss risk assessment in the USA, specifically, at Mass General Brigham and Vanderbilt University Medical Center.

Computer-based guidelines:

Dr. Kimberly Blumenthal shows us how her hospital system, Mass General Brigham (with multiple hospitals in Massachusetts and New Hampshire), uses computerised guidance and applications to assess the procedures to follow in terms of penicillin allergy.

Mass General Brigham’s penicillin pathway for hospitalised patients is shown in the infographic below.

A screen-reader compatible version of the above image is available here. A full-size version of this image is available here.

Computer algorithms can use the allergy history to detect if the same or a cross-reactive drug has been ordered for the allergic patient and will produce an alert that prevents the order from following through. The clinician must then update the patient’s records and can order a non-cross-reactive drug, which also has computerised guidance attached.

Implementing these computer-based guidelines into the hospital environment has led to a large reduction in second line alternatives and adverse effects associated with non-beta-lactam drugs. It also led to an increase in the frequency of optimal therapy for methicillin-susceptible Staphylococcus aureus (MSSA) bacteraemia, as illustrated by the following infographic. If you would like to read this study in full, please click here.

A full-size version of the above image is available by clicking here.

Computer-based algorithms help to avoid the need for skin testing in patients that otherwise refuse to partake in these trials. Barriers to getting tested include patient-specific factors such as refusal, acute medical issues and transferring to other hospitals, as well as other factors such as the inpatient team refusing and lack of coordination in delabelling before discharge.

More manuscripts on this approach seen in Mass General Brigham’s practice can be seen here and here.

Penicillin allergy delabelling in the medical intensive care unit (MICU):

Dr. Cosby Stone describes a study on penicillin allergy delabelling in the MICU of Vanderbilt University Medical Center in Nashville.

Patients in the MICU are often burdened with comorbid immune compromise and multiple drug allergy labels. Of all patients admitted to the MICU, 16.1% had a penicillin allergy label. This study aimed to determine the safety and efficacy of penicillin allergy delabelling via a direct oral challenge in this patient population.

The electronic health records used at Vanderbilt University Medical Center were used to highlight patients with penicillin allergy label who subsequently were assessed over a 2-year period for the inclusion of oral challenge testing. To meet the criteria, patients needed to be haemodynamically stable, not pregnant, cognitively capable of providing medical history, and their penicillin allergy label assessed as low risk.

To be considered low risk, the following medical history criteria had to be met:

1. Isolated urticaria more than 5 years ago,
2. Self-limited cutaneous rash at any point in the past without any organ involvement or signs of a severe delayed rash,
3. Gastrointestinal symptoms only,
4. Remote childhood reaction with limited details,
5. Family history of penicillin allergy only,
6. Avoidant from fear of allergy only,
7. Known tolerance of penicillin since the original reaction occurred, or
8. Other nonallergy symptoms.

Of those patients eligible for the initial oral challenge, 100% passed after one hour, leading to fully documented delabelling. It should be noted that some patients did go on to have minor reactions, but their records were adjusted accordingly, not necessarily being relabelled as penicillin allergic. Of these patients, 32.9% collectively tolerated 49 subsequent penicillin treatments.

Performing point-of-care penicillin allergy delabelling in MICU patients with low-risk penicillin allergy labels was a good way to prioritise those most likely to benefit from delabelling, especially those who were immunocompromised. If you are interested in reading this study in full, please find the 2022 study here.

In the comments below, we encourage you to discuss the penicillin allergy risk assessment tools that are available at your place of work. Were you familiar with the techniques mentioned in these articles?

In the next activity, we look into the governance currently surrounding penicillin allergy delabelling and how to successfully implement a penicillin allergy assessment service. Click ‘next’ to continue.