Purpose: The most commonly reported medication allergies in the United States involve beta-lactam antibiotics, creating an important consideration for prescribers when choosing optimal treatment of infections. Currently, few data exist on outpatient prescribing patterns in response to patients with a beta-lactam allergy. This study sought to evaluate the appropriateness of outpatient antibiotic therapy in patients with documented beta-lactam allergies within a Veterans Affairs health care system to evaluate areas of improvement in prescribing practices.
Methods: Patients receiving outpatient oral antibiotics were prospectively identified through real-time electronic alerts from June 2017 through February 2018. Prescriptions were then reviewed retrospectively to identify appropriateness of antibiotic, drug choice, dose, and duration based on current guideline recommendations. Data were compared between patients with a listed beta-lactam allergy and patients without a beta-lactam allergy to determine the impact on prescribing patterns and outcomes. Baseline characteristics were compared by using descriptive statistics. Significant risk factors for inappropriate prescribing were identified through a multivariable analysis.
Findings: The cohort included 1844 antibiotic prescriptions (documented beta-lactam allergy, 221; no beta-lactam allergy, 1623). Appropriate drug, dose, and duration for antibiotics prescribed in patients reporting a beta-lactam allergy versus nonallergic patients were 44.3% versus 53.0% (P = 0.02), 91.4% versus 86.2% (P = 0.03), and 75.1% versus 76.2% (P = 0.83), respectively. Patients with a reported beta-lactam allergy were 31% less likely to receive the correct drug for indication empirically (95% CI, 0.52-0.92) in the multivariable regression model when adjusted for fluoroquinolone use. In addition, patients reporting a beta-lactam allergy were 2.2 times (95% CI, 1.6-3.0) more likely to receive a fluoroquinolone antibiotic. Antibiotics were considered overall inappropriate based on at least one aspect of therapy in 79.6% of patients reporting a beta-lactam allergy and in 71% of nonallergic patients.
Implications: Antibiotic therapy in patients with a documented beta-lactam allergy was less likely to be appropriate overall, suggesting an area of improvement for prescribing habits. Future interventions should focus on prescriber education regarding first-line and alternative treatments for patients with beta-lactam allergies to ensure that optimal treatment is being provided.
Keywords: allergy; antibiotic; antimicrobial stewardship; beta-lactam; drug utilization review; stewardship.
Published by Elsevier Inc.