University at Buffalo School of Pharmacy, Buffalo, NY, USA.
Department of Pharmacy, Veterans Affairs Western New York Healthcare System, Buffalo, NY, USA.
Clin Ther. 2019 Dec;41(12):2529-2539. doi: 10.1016/j.clinthera.2019.10.001. Epub 2019 Oct 26.
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.
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.
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.
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.
在美国，最常报告的药物过敏涉及β-内酰胺类抗生素，这对临床医生在选择感染的最佳治疗方案时非常重要。目前，针对有β-内酰胺类抗生素过敏的患者，关于门诊处方模式的数据很少。本研究旨在评估退伍军人事务医疗保健系统中，有β-内酰胺类抗生素过敏史的患者的门诊抗生素治疗的合理性，以评估在处方实践方面的改进空间。
通过 2017 年 6 月至 2018 年 2 月实时电子警报，前瞻性识别接受门诊口服抗生素治疗的患者。然后，回顾性审查处方，根据当前指南建议，确定抗生素的适宜性、药物选择、剂量和疗程。比较有β-内酰胺类过敏史的患者和无β-内酰胺类过敏史的患者的处方模式和结果，以确定其对处方模式的影响。使用描述性统计方法比较基线特征。通过多变量分析确定不适当处方的显著危险因素。
该队列纳入了 1844 份抗生素处方（有β-内酰胺类过敏史 221 例，无β-内酰胺类过敏史 1623 例）。与无过敏史的患者相比，报告β-内酰胺类过敏的患者接受适宜药物、剂量和疗程治疗的比例分别为 44.3%和 53.0%（P=0.02）、91.4%和 86.2%（P=0.03）、75.1%和 76.2%（P=0.83）。在多变量回归模型中，当调整氟喹诺酮类药物使用情况时，报告有β-内酰胺类过敏的患者接受经验性治疗适应证正确药物的可能性降低 31%（95%CI，0.52-0.92）。此外，报告有β-内酰胺类过敏的患者接受氟喹诺酮类抗生素治疗的可能性增加 2.2 倍（95%CI，1.6-3.0）。根据治疗的至少一个方面，有β-内酰胺类过敏史的患者中，79.6%的抗生素处方和无过敏史患者中 71%的抗生素处方被认为总体上不适当。
有β-内酰胺类过敏史的患者的抗生素治疗总体上不太可能是适宜的，这表明处方习惯需要改进。未来的干预措施应侧重于针对有β-内酰胺类过敏的患者的一线和替代治疗方法，为其提供最佳治疗。
