Impact of a Fully Integrated Regional Antibiotic Stewardship Program and Penicillin Allergy Delabeling on Antibiotic Utilization, Clinical Outcomes, and Costs

Eric Macy, MD, MS; Katie Sharff, MD; Tracy Barton, PharmD; Steve Spindel, MD; Andrew Leitz, MD, PhD; Jodi Longueil, PharmD

Abstracts from the Kaiser Permanente 2020 National Quality Conference

From Northwest, Southern California

Background: Antibiotic resistance is a growing problem in the US with a least 2 million people infected annually with resistant bacteria. The use of antibiotics is the most important factor leading to antibiotic resistance around the world, and up to 30% of prescribed antibiotics are unnecessary. Improving antibiotic use is a medication and a patient-safety issue.
Methods: The fully integrated Kaiser Permanente (KP) Northwest (KPNW) Antibiotic Stewardship Program (ASP) team collaborates for virtual rounding and reviews patients receiving high interest antimicrobials. Feedback is directly provided to clinicians. Blood cultures for the Region are monitored by an infectious disease pharmacist to ensure appropriate treatment. Change is driven by leveraging education and informatics. Penicillin allergy delabeling includes low-risk allergic individuals with history of benign rash more than 1 year previously, somatic symptoms, or unknown history. These patients receive oral amoxicillin 250-mg challenge and 1 hour of observation to rule out clinically significant immunoglobulin E (IgE)-mediated hypersensitivity and 5 days of observation to rule out a delayed-onset T-cell-mediated hypersensitivity.
Results: The KPNW integrated team approach to antimicrobial stewardship has the lowest days of therapy per 1000 patient days for broad-spectrum antibiotic utilization and the lowest antibiotic cost per 1000 patient days compared with the other KP Regions from 2017 through 2019. The San Diego Service penicillin allergy tested 1205 adults and children. Of the 399 (33.1%) who underwent skin testing first, 6 (1.5%) were skin test positive. There were 7 (1.8%) skin test negative individuals who had acute positive oral challenge reactions. In the 806 (66.9%) who had a direct oral amoxicillin challenge, 2 (0.2%) had acute positive reactions and 9 (1.1%) had delayed positive reactions. There were 25 (2.1%) confirmed to have an IgE or T-cell-mediated hypersensitivity.
Discussion: ASP has been shown to optimize the treatment of infections and reduce adverse events associated with antibiotic use while reducing the potential to develop resistant infections, thus preserving the therapeutic effectiveness of antimicrobials. Accurate allergy information drives optimal antibiotic choice. KPNW’s patient-centered ASP model and KP Southern California’s penicillin delabeling program are models that could be expanded to other KP Regions to improve stewardship outcomes.



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