Penicillin Skin Testing in the ICU is Associated With a Greater Change to Narrow-Spectrum Antibiotics

      SESSION TITLE: Allergy and Asthma
      SESSION TYPE: Original Investigation Poster
      PRESENTED ON: Wednesday, November 1, 2017 at 01:30 PM - 02:30 PM
      PURPOSE: A documented penicillin allergy is associated with increased morbidity including length of hospital stay and an increased incidence of multi-drug resistant infections attributed to use of broader-spectrum antibiotics. Over 90% of patients with a history of penicillin allergy tolerate beta-lactams without adverse effects. Penicillin skin testing (PST) is a valid skin test to rule a penicillin allergy. However, there are concerns on its validity and reproducibility in the intensive care unit (ICU). The primary aim of this systematic review and meta-analysis was to ascertain the validity of PST in the ICU. The secondary aim was to identify whether PST in the ICU led to a change of antibiotic selection.
      METHODS: We performed an electronic search of Ovid Medline/PubMed, Embase, Web of Science, Scopus and the Cochrane Library over the past 20 years. Studies of exclusive ICU and general inpatient cohorts with a documented penicillin allergy who underwent PST were included. We performed a pooled cohort meta-analysis to compare the proportion of negative PSTs between the ICU and inpatient cohorts. We also compared the change in antibiotic selection between the two groups following testing.
      RESULTS: Seventeen studies were identified. Six studies had exclusive intensive care unit (ICU) cohorts and eleven had a general inpatient population. Median study sample size in the ICU was 71 patients (range 24-146; SD 48.65) and 76 patients (range 16-252; SD 67.48) in inpatient cohorts (p=0.53). The population-weighted mean for a negative PST was 95.03% (CI 92.5-96.7) in the ICU versus 92.2% (CI 90.4-93.8) in the inpatient population (p=0.74). Inpatient penicillin skin testing led to selection of narrow-spectrum antibiotics in both groups. This was greater in the ICU setting (77.97% [CI 72.0-83.1] versus 54.74% [CI 51.2-58.2]), p <0.01.
      CONCLUSIONS: Penicillin skin testing is a valid and effective test in ruling out penicillin allergy in the ICU. Changes in antibiotic selection are more pronounced in the ICU setting.
      CLINICAL IMPLICATIONS: Patients with a documented penicillin allergy who require beta-lactams should be tested during hospitalization given its benefit for individual patient outcomes and antibiotic stewardship.
      DISCLOSURE: The following authors have nothing to disclose: Keith Sacco, Scott Helgeson, J Saadi Imam, M Burton
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