Documenting Penicillin Allergy: The Impact of Inconsistency

• Published in: PloS one Vol. 11; no. 3; p. e0150514
• Main Authors: Shah, Nirav S., Ridgway, Jessica P., Pettit, Natasha, Fahrenbach, John, Robicsek, Ari
• Format: Journal Article
• Language: English
• Published: United States Public Library of Science 16.03.2016; Public Library of Science (PLoS)
• Subjects: Allergens; Allergies; Ambulatory care; Amides; Amoxicillin; Antibiotics; Antimicrobial agents; Beta lactam antibiotics; Binomial distribution; Biology and Life Sciences; Cephalosporins; Clindamycin; Complications and side effects; Confidence intervals; Documentation; Drug Hypersensitivity - diagnosis; Female; Fluoroquinolones; Health care; Hospitals; Humans; Hypersensitivity; Internal medicine; Male; Medical records; Medicine; Medicine and Health Sciences; Middle Aged; Patients; Penicillin; Penicillins - adverse effects; People and Places; Physicians; Primary care; Retrospective Studies; Sensitivity and Specificity; Staphylococcus infections; Supply and demand; Vancomycin; United States > US; Illinois; Chicago Illinois
• ISSN: 1932-6203; 1932-6203
• DOI: 10.1371/journal.pone.0150514

Allergy documentation is frequently inconsistent and incomplete. The impact of this variability on subsequent treatment is not well described. To determine how allergy documentation affects subsequent antibiotic choice. Retrospective, cohort study. 232,616 adult patients seen by 199 primary care providers (PCPs) between January 1, 2009 and January 1, 2014 at an academic medical system. Inter-physician variation in beta-lactam allergy documentation; antibiotic treatment following beta-lactam allergy documentation. 15.6% of patients had a reported beta-lactam allergy. Of those patients, 39.8% had a specific allergen identified and 22.7% had allergic reaction characteristics documented. Variation between PCPs was greater than would be expected by chance (all p<0.001) in the percentage of their patients with a documented beta-lactam allergy (7.9% to 24.8%), identification of a specific allergen (e.g. amoxicillin as opposed to "penicillins") (24.0% to 58.2%) and documentation of the reaction characteristics (5.4% to 51.9%). After beta-lactam allergy documentation, patients were less likely to receive penicillins (Relative Risk [RR] 0.16 [95% Confidence Interval: 0.15-0.17]) and cephalosporins (RR 0.28 [95% CI 0.27-0.30]) and more likely to receive fluoroquinolones (RR 1.5 [95% CI 1.5-1.6]), clindamycin (RR 3.8 [95% CI 3.6-4.0]) and vancomycin (RR 5.0 [95% CI 4.3-5.8]). Among patients with beta-lactam allergy, rechallenge was more likely when a specific allergen was identified (RR 1.6 [95% CI 1.5-1.8]) and when reaction characteristics were documented (RR 2.0 [95% CI 1.8-2.2]). Provider documentation of beta-lactam allergy is highly variable, and details of the allergy are infrequently documented. Classification of a patient as beta-lactam allergic and incomplete documentation regarding the details of the allergy lead to beta-lactam avoidance and use of other antimicrobial agents, behaviors that may adversely impact care quality and cost.