Download Guidance for NHS Grampian Staff on Antibiotic Choice for Patients

Guidance For NHS Grampian Staff On
Antibiotic Choice For Patients With
Penicillin Hypersensitivity
Lead
Author/Coordinator:
Gillian Macartney / Fiona
McDonald
Specialist Antibiotic
Pharmacists
Reviewer:
Approver:
Dr Alexander Mackenzie
Consultant Infectious
Diseases, Chair of
Antimicrobial Group
Dr Caroline Hind
Chair of Medicines
Guidelines and Policies
Group
Signature:
Signature:
Signature:
Identifier:
NHSG/Guid/PenA/
MGPG754
Review Date:
July 2017
Approval Date:
July 2015
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Version 4
Executive Sign-Off
This document has been endorsed by the Director of Pharmacy and Medicines
Management
Signature:___________________________________________
This document is also available in large print and
other formats and languages, upon request. Please
call NHS Grampian Corporate Communications on
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This controlled document shall not be copied in part or whole without the express permission
of the author or the author’s representative.
Title:
Guidance For NHS Grampian Staff On Antibiotic Choice For
Patients With Penicillin Hypersensitivity
Unique Identifier:
NHSG/Guid/PenA/MGPG754
Replaces:
NHSG/Guid/PenA/MGPG 593, Version 3
Lead Author/Coordinator:
Specialist Antibiotic Pharmacists
Subject
Prescribing and Prescription
Key word(s):
Antibiotic, Antibiotics, Antimicrobial, Antimicrobials,
Penicillin, Beta-lactams, Allergy, Hypersensitivity
Policy, Protocol, Procedure
or Process Document:
Guidance (Antimicrobial Prescribing Guidance)
Document application:
NHS Grampian
Purpose/description:
To define penicillin or beta-lactam allergy and direct to
guidelines for treatment options.
Group/Individual
responsible for this
document:
Specialist Antibiotic Pharmacists
Policy statement:
It is the responsibility of all staff to ensure that they are
working to the most up-to-date and relevant policies,
protocols and procedures.
It is the responsibility of individual prescribers to ensure the
management of infections in primary care patients is within
the guidance laid down in this document. By doing so, the
quality of the services offered will be maintained, and the
chances of staff making erroneous decisions which may
affect patient, staff or visitor safety and comfort will be
reduced.
UNCONTROLLED WHEN PRINTED
Review Date: July 2017
Identifier: NHSG/Guid/PenA/MGPG754
NHS Grampian Staff Guidance on Antibiotic Choice for Patients with Penicillin Hypersensitivity - Version 4
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Responsibilities for ensuring registration of this document on the NHS Grampian
Information/Document Silo:
Development Pharmacist – Medicines Management
Physical location of the
original of this document:
Job title of creator of this
document:
Job/group title of those
who have control over this
document:
Responsibilities for
disseminating document as
per distribution list:
Pharmacy and Medicines Directorate, Westholme
Specialist Antibiotic Pharmacists
Specialist Antibiotic Pharmacists
Specialist Antibiotic Pharmacists
Responsibilities for implementation:
Organisational:
Sector
Departmental:
Area:
Operational Management Team and Chief Executive
General Managers, Medical Leads and Nursing Leads
Clinical Leads
Line Manager
Review frequency and date
of next review:
Every two years (or sooner if required); next review July
2017
Responsibilities for review of this document:
Lead Author/Co-ordinator:
Specialist Antibiotic Pharmacists
Revision History:
Previous
Revision
Revision
Date
Date
June 2015
June 2013
June 2015
June 2013
June 2015
June 2013
Summary of Changes
(Descriptive summary of the
changes made)
Aztreonam cross-sensitivity
added.
References 2, 10 and 11
added.
Changes Marked*
(Identify page numbers
and section heading )
Page 3
Page 4
Ampicillin, ticarcillin,
Page 6
ceftobiprole, fosfomycin added
to chart.
* Changes marked should detail the section(s) of the document that have been amended i.e.
page number and section heading.
UNCONTROLLED WHEN PRINTED
Review Date: July 2017
Identifier: NHSG/Guid/PenA/MGPG754
NHS Grampian Staff Guidance on Antibiotic Choice for Patients with Penicillin Hypersensitivity - Version 4
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Guidance For NHS Grampian Staff On Antibiotic Choice For Patients With
Penicillin Hypersensitivity
Contents
Page No
Introduction ................................................................................................................. 2
What is the True Incidence of ‘Penicillin Allergy’? ...................................................... 2
Who is at risk? ............................................................................................................ 2
Recording Drug Allergies ............................................................................................ 2
Who should not be prescribed or administered penicillins? ........................................ 3
Are there situations where cephalosporins or other beta-lactam antibiotics can be
prescribed for patients with penicillin hypersensitivity? ............................................... 3
Which antibiotics can I use in a penicillin allergic patient? .......................................... 3
What should be prescribed empirically for truly penicillin allergic patients? ................ 3
References ................................................................................................................. 4
Consultation List ......................................................................................................... 4
Distribution list ............................................................................................................ 5
Appendix 1: Penicillin Allergy Poster .......................................................................... 6
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Identifier: NHSG/Guid/PenA/MGPG754
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Guidance For NHS Grampian Staff On Antibiotic
Choice For Patients With Penicillin Hypersensitivity
Introduction
The phrase ‘allergic to penicillin’ is commonly seen in medical notes and on medicine
charts. The diagnosis of ‘penicillin allergy’ is often simply accepted without obtaining
a detailed history of the reaction. It has been reported that a significant percentage
(up to 90%) of patients labelled as ‘penicillin allergic’ are not truly allergic to the drug
(1, 2). As a result, penicillins are unnecessarily withheld as a treatment option for
these patients, which may subsequently affect their clinical outcomes. Alternatives to
penicillins may be broader spectrum, more costly, and have the potential for more
adverse reactions (including Clostridium difficile), and induction of antimicrobial
resistance (3,4). The in-patient antibiotic cost of managing a patient with an allergy
to penicillin has been reported to be more than 60% higher than that of a patient who
can tolerate a penicillin (5).
What is the True Incidence of ‘Penicillin Allergy’?
General hypersensitivity reactions (e.g. rashes) to penicillin occur in between 1% and
10% of exposed patients but true anaphylactic reactions (which can be fatal) occur in
less than 0.05% of treated patients (6). Hypersensitivity to penicillin gives rise to
immediate reactions including anaphylaxis, angioedema, urticaria, and some
maculopapular rashes. Late reactions may include serum sickness-like reactions
and haemolytic anaemia (7).
Individuals with a history of a minor rash (i.e. non-confluent, non-pruritic rash
restricted to a small area of the body) or a rash that occurs more than 72 hours after
penicillin administration are probably not allergic to penicillin and in these individuals
a penicillin should not be withheld unnecessarily for serious infections; the possibility
of an allergic reaction should, however, be borne in mind. Other beta-lactam
antibiotics (including cephalosporins) can be used in these patients (6).
Please note that patients who have a vague history of symptoms or gastro-intestinal
intolerance are probably not truly allergic to penicillins. Clinical judgement must be
used if adequate information about a patient’s history of penicillin allergy is difficult to
obtain.
Who is at risk?
Patients with a history of atopic allergy (e.g. asthma, eczema, hay fever) are more
likely to be allergic to penicillins (6).
Recording Drug Allergies
NHS Grampian policy states that any known drug/medicine sensitivity should be
entered in the appropriate box on the prescription and administration record (PAR) at
the time of admission or as this information becomes available. The information
recorded should include the drug name and the nature of the reaction.
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Who should not be prescribed or administered penicillins?
Individuals with a history of immediate hypersensitivity following penicillin
administration, clinically recognisable by features of urticaria, laryngeal oedema,
bronchospasm, hypotension or local swelling within 72 hours of administration
should NOT receive a penicillin. Patients who are allergic to one penicillin will be
allergic to all because the hypersensitivity is related to the basic penicillin structure.
In cases of intolerance to penicillins (e.g. gastrointestinal upset) or development of a
rash 72 hours after administration, penicillins/related antibiotics should not be
withheld unnecessarily in severe infection but the patient must be monitored closely
after administration. Treatment options in these patients should be discussed with
medical microbiology or an infection specialist.
Are there situations where cephalosporins or other beta-lactam antibiotics can
be prescribed for patients with penicillin hypersensitivity?
The incidence of cross-reactivity to cephalosporins in penicillin-allergic patients is
0.5% - 6.5% (6). Second and third generation cephalosporins are less likely to be
associated with cross reactivity as they have different side chains to penicillin.
If a cephalosporin is essential (e.g. in life threatening infections) in these patients
because a suitable alternative antibacterial is not available, then cefixime,
cefotaxime, ceftazidime, ceftriaxone, or cefuroxime can be used with caution. Avoid
cefalexin and cefradine (6).
Carbapenems (e.g. meropenem, ertapenem) and monobactams (e.g. aztreonam)
should also be used with caution in patients with a history of an immediate
hypersensitivity reaction (6); very low rates of cross-sensitivity have been reported
(9,11).
Which antibiotics can I use in a penicillin allergic patient?
Antibiotics which are unrelated to penicillins and safe to use include:
•
•
•
•
•
•
•
•
•
•
Tetracyclines (e.g. doxycyline)
Aminoglycosides (e.g. gentamicin)
Macrolides (e.g. clarithromycin)
Clindamycin
Sulphonamides (e.g. co-trimoxazole)
Trimethoprim
Metronidazole
Quinolones (e.g. ciprofloxacin)
Vancomycin or teicoplanin
Fosfomycin
What should be prescribed empirically for truly penicillin allergic patients?
See Grampian Joint Formulary for full guidelines.
For information on which antibiotics should be avoided in penicillin allergy, those that
should be used with caution, and those that are safe see Appendix 1.
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References
1.
Yates AB. Management of patients with a history of allergy to beta-lactam
antibiotics. The American Journal of Medicine 2008; 121(7); 572-76
2.
NICE Clinical guideline 183 Sept 2014: Drug allergy: diagnosis and
management of drug allergy in adults, children and young people
https://www.nice.org.uk/guidance/cg183
3.
Borch JE, Andersen KE, Bindslev-Jensen C. The prevalence of suspected and
challenge-verified penicillin allergy in a University Hospital population. Basic &
Clinical Pharmacology & Toxicology 2006;98: 357-362
4.
MacLaughlin EJ, Saseen JJ, Malone DC. Costs of b-lactam allergies: Selection
& costs of antibiotics for patients with a reported b-lactam allergy. Archives of
Family Medicine 2000;9:722-26
5.
Sade K, Holtzer I, Levo Y, Kivity S. The economic burden of antibiotic
treatment of penicillin-allergic patients in internal medicine wards of a general
tertiary care hospital. Clin Exp Allergy 2003; 33(4): 501-6
6.
British National Formulary 65 March 2013 at
https://www.medicinescomplete.com/mc/bnf/current/
7.
Martindale: The Complete Drug Reference [accessed via
www.medicinescomplete.com]
8.
UKMI Medicines Q&A 181.2. “Is there a 10% cross-sensitivity between
penicillins and cephalosporins?” [accessed via
http://www.evidence.nhs.uk/Search?pa=2&q=penicillin+%26+cephalosporin+all
ergy
9.
Hawkey PM, Livermore DM. Carbapenem antibiotics for serious infections.
BMJ 2012;344:e3236 doi: 10.1136/bmj.e3236 (Published 31 May 2012)
10. Saxon A, et al. Immediate hypersensitivity reactions to beta-lactam antibiotics.
Ann. Inter. Med. 1987;107(2): 204-15
11. Gaeta F, et al. Tolerability of aztreonam and carbapenems in patientswith IgEmediated hypersensitivity to penicillins J. Allergy Clin. Immunol. ‘Article in
press’ 2014 (http://dx.doi.org/10.1016/j.jaci.2014.10.011)
Consultation List
The document (including summary guide) was originally developed in consultation
with:
•
•
•
•
•
•
•
All Consultants
Group Pharmacy
HSCP Pharmacists
HSCP Clinical Hospital Leads
Medical Microbiology Registrars
Non-Medical Prescribers
Unit Nurse Managers
Review consultation list (for 2015 update):
•
•
All acute sector pharmacists
Medical Microbiology
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This policy has been reviewed and agreed by;
•
•
NHS Grampian Antimicrobial Management Team – July 2015
NHS Grampian Medicines and Guidelines Group – July 2015
Distribution list
•
•
•
•
•
•
•
•
All Consultants
Group Pharmacy
HSCP Clinical Hospital Leads
HSCP Pharmacists
Medical Microbiology Registrars
Non-Medical Prescribers
Unit Nurse Managers
GP Practices
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Review Date: July 2017
Identifier: NHSG/Guid/PenA/MGPG754
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Penicillin Allergy
All drug-allergies must be specified on medication charts (with the patient’s reaction)
In TRUE
penicillin1:
allergy*
ALL penicillins, cephalosporins and other beta-lactam antibiotics should be avoided
Appendix
Penicillin
Allergy Poster
Antibiotics to be avoided in
penicillin allergy
CONTRAINDICATED
Amoxicillin
Benzylpenicillin
Co-amoxiclav (Augmentin®)
Flucloxacillin
Penicillin V (phenoxymethylpenicillin)
Piperacillin / Tazobactam (Tazocin®)
Pivmecillinam
Temocillin
Ticarcillin (Timentin®)
1st generation Cephalosporins
Cefradine, Cefalexin
CAUTION
Use with caution
if non-severe allergy
(e.g. minor rash or rash
after 72 hours)
Antibiotics to be used with
caution in non-severe penicillin
allergy
Other Cephalosporins:
Cefixime, Cefotaxime, Ceftazidime,
Ceftriaxone, Ceftobiprole, Cefuroxime
Other beta-lactam antibiotics
Aztreonam, Ertapenem, Imipenem,
Meropenem
Antibiotics safe in penicillin
allergy (not an exhaustive list)
CONSIDERED
SAFE
Amikacin
Azithromycin
Ciprofloxacin
Clarithromycin
Clindamycin
Colistin
Co-trimoxazole
Daptomycin
Doxycycline
Erythromycin
Fosfomycin
Gentamicin
Levofloxacin
Linezolid
Metronidazole
Nitrofurantoin
Ofloxacin
Rifampicin
Sodium Fusidate
Teicoplanin
Tetracycline
Tigecycline
Tobramycin
Trimethoprim
Vancomycin
*TRUE penicillin allergy includes anaphylaxis, urticaria or rash immediately after penicillin administration.
In cases of INTOLERANCE to penicillins (e.g. gastrointestinal upset) or a rash occurring >72 hours after
administration, penicillins/ related antibiotics should not be withheld unnecessarily in severe infection but the patient
must be monitored closely after administration.
The full guidance on antibiotic choice for patients with penicillin hypersensitivity is available at
www.nhsgrampian.org/gjf - Chapter 5 Infections
NHS Grampian Antimicrobial Management Team (with thanks to NHS Tayside)
June 2015
Review: June 2017
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Review Date: July 2017
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