The Impact of Reported Beta-Lactam Allergy in Hospitalized Patients With Hematologic Malignancies Requiring Antibiotics.

Background: Patients hospitalized with hematologic malignancy are particularly vulnerable to infection. The impact of reported beta-lactam (BL) allergy in this population remains unknown. Methods: This was a retrospective cohort study of adult inpatients with hematologic malignancy admitted at 2 tertiary care hospitals from 2010 through 2015. The primary outcome was hospital length of stay (LOS) after administration of the first antibiotic. Secondary outcomes included readmission, mortality, complications, hospital charges, and antibiotic usage. Our goal was to define the impact of BL-only allergy (BLOA) label on clinical outcomes compared to those with no BL allergy (NBLA) in hematologic malignancy inpatients who required systemic antibiotics. Results: In our cohort (n = 4671), 38.3% had leukemia, 4.9% had Hodgkin lymphoma, 36.1% had non-Hodgkin lymphoma, and 20.7% had multiple myeloma. Among patients, 35.1% reported antibiotic allergy, and 14.1% (n = 660) had BLOA (including 9.3% with penicillin-only allergy and 3.3% cephalosporin-only allergy). Patients with BLOA had longer median LOS compared to patients with NBLA (11.3 vs 7.6 days, P < .001), which remained significant after multivariable adjustment. Patients with BLOA also had significantly worse outcomes in terms of mortality rate at 30 days (7.6% vs 5.3%, P = .017) and 180 days (15.8% vs 12.2%, P = .013), 30-day readmission rate, Clostridium difficile rate, hospital charges ($223 046 vs $173 256, P < .001), antibiotic classes used, and antibiotic duration. Conclusions: In hospitalized patients with hematologic malignancy, patients with reported BL allergy had worse clinical outcomes and higher healthcare cost than those without BL allergy label.

Symptom-Based Clustering in Chronic Rhinosinusitis Relates to History of Aspirin Sensitivity and Postsurgical Outcomes.

BACKGROUND: Symptoms burden in chronic rhinosinusitis (CRS) may be assessed by interviews or by means of validated tools such as the 22-item SinoNasal Outcome Test (SNOT-22). However, when only the total SNOT-22 scores are used, the pattern of symptom distribution and heterogeneity in patient symptoms is lost. OBJECTIVES: To use a standardized symptom assessment tool (SNOT-22) on preoperative symptoms to understand symptom heterogeneity in CRS and to aid in characterization of distinguishing clinical features between subgroups. METHODS: This was a retrospective review of 97 surgical patients with CRS. Symptom-based clusters were derived on the basis of presurgical SNOT-22 scores using unsupervised analysis and network graphs. Comparison between clusters was performed for clinical and demographic parameters, postsurgical symptom scores, and presence or absence of a history of aspirin sensitivity. RESULTS: Unsupervised analysis reveals coclustering of specific symptoms in the SNOT-22 tool. Using symptom-based clustering, patients with CRS were stratified into severe overall (mean total score, 90.8), severe sinonasal (score, 62), moderate sinonasal (score, 40), moderate nonsinonasal (score, 37) and mild sinonasal (score, 16) clusters. The last 2 clusters were associated with lack of history of aspirin sensitivity. The first cluster had a rapid relapse in symptoms postoperatively, and the last cluster demonstrated minimal symptomatic improvement after surgery. CONCLUSION: Symptom-based clusters in CRS reveal a distinct grouping of symptom burden that may relate to aspirin sensitivity and treatment outcomes.

Anaphylaxis in the young adult population.

It is critical that clinicians treating young adults understand the presentation and management of anaphylaxis. The most common trigger for anaphylaxis in this population is food. The prevalence of food allergy is growing, with 8% of US children and adolescents affected. All patients at risk for anaphylaxis should be prescribed epinephrine autoinjectors, as epinephrine is the only life-saving medication for a severe anaphylactic reaction. The presentation of anaphylaxis can involve multiple organ systems (eg, mucocutaneous, respiratory, cardiovascular, gastrointestinal) and, as such, patient education is needed to assist in prompt recognition. Appropriate training of patients and caregivers about how to identify anaphylaxis and what to do in an emergency is critical. Training of school and college staff also is essential, as 1 in 4 first-time reactions occurs outside the home. Additional counseling for adolescents at risk for anaphylactic reactions should address increased risk-taking behavior, decreased adult supervision, dating, and the transition of disease management from an adult to the patient.

Health care use and serious infection prevalence associated with penicillin "allergy" in hospitalized patients: A cohort study.

BACKGROUND: Penicillin is the most common drug "allergy" noted at hospital admission, although it is often inaccurate. OBJECTIVE: We sought to determine total hospital days, antibiotic exposures, and the prevalence rates of Clostridium difficile, methicillin-resistant Staphylococcus aureus (MRSA), and vancomycin-resistant Enterococcus (VRE) in patients with and without penicillin "allergy" at hospital admission. METHODS: We performed a retrospective, matched cohort study of subjects admitted to Kaiser Foundation hospitals in Southern California during 2010 through 2012. RESULTS: It was possible to match 51,582 (99.6% of all possible cases) unique hospitalized subjects with penicillin "allergy" to 2 unique discharge diagnosis category-matched, sex-matched, age-matched, and date of admission-matched control subjects each. Cases with penicillin "allergy" averaged 0.59 (9.9%; 95% CI, 0.47-0.71) more total hospital days during 20.1 ± 10.5 months of follow-up compared with control subjects. Cases were treated with significantly more fluoroquinolones, clindamycin, and vancomycin (P < .0001) for each antibiotic compared with control subjects. Cases had 23.4% (95% CI, 15.6% to 31.7%) more C difficile, 14.1% (95% CI, 7.1% to 21.6%) more MRSA, and 30.1% (95% CI, 12.5% to 50.4%) more VRE infections than expected compared with control subjects. CONCLUSIONS: A penicillin "allergy" history, although often inaccurate, is not a benign finding at hospital admission. Subjects with a penicillin "allergy" history spend significantly more time in the hospital. Subjects with a penicillin "allergy" history are exposed to significantly more antibiotics previously associated with C difficile and VRE. Drug "allergies" in general, but most those notably to penicillin, are associated with increased hospital use and increased C difficile, MRSA, and VRE prevalence.

Commentary: "Who was caring for Mary?" revisited: a call for all academic physicians caring for patients to focus on systems and quality improvement.

Over 15 years have passed since Mary's near death (Annals of Internal Medicine. 1993;118:146-148). Disappointment in the care by fellow academic physicians persists; however, a reanalysis of her case through the lens of complex systems design and performance yields a more accurate and actionable perspective. Mary's suffering was not due to human failure alone. Human failure was provoked and exacerbated by broken processes including ambiguous assignments of responsibility; inadequate transfers of information and authority; unreliable or unavailable protocols for providing safe, effective treatment; and a failure to integrate the deep but narrow perspectives of individual specialists into a complete picture of Mary's condition. Her case exemplifies, in personal terms, many of the system challenges academic medical centers face: Faculty have other missions that can conflict with patient care; disease complexity is high, requiring input from multiple subspecialists; clinical departments serve as roadblocks to communication; and novice physicians, requiring close supervision, have primary responsibility for the day-to-day care of acutely ill patients. The academic physicians who first cared for Mary unwittingly accepted flawed systems, and they failed to work around them. At great monetary and emotional expense, last-minute heroics saved Mary. In a dysfunctional system, even the most conscientious physician may be viewed as uncaring. As Mary's case so clearly illustrates, patients and their families see the system and the physician as one. Only by working to improve the systems of delivery will academic physicians again be consistently viewed as caring.

Causality assessment in drug-induced hepatotoxicity.

Drugs are currently an important cause of liver disease, ranked as the most frequent reason for acute liver failure. Despite recent advances in knowledge of the mechanisms implicated in drug-induced hepatocellular damage and cholestasis, as well as the identification of several risk factors, the diagnosis of hepatotoxicity remains a difficult task because specific tests are not available. In a step-by-step approach, the incrimination of a drug in liver symptoms requires a high degree of suspicion on the part of the physician, temporal eligibility, awareness of the drug's hepatotoxic potential, the exclusion of alternative causes of liver damage, and the ability to detect the presence of subtle data that favour a toxic aetiology. Ultimately, the use of diagnostic algorithms may add consistency to the diagnostic process either by translating the suspicion into a quantitative score or by providing a framework that emphasises the features that merit attention in cases of suspected hepatic adverse reactions.

Medication errors: 1977 to 1988. Experience in medical malpractice claims.

MIIENJ has paid $30,144,636 in indemnity from 1977 through 1988 for medical malpractice suits arising from medication errors. A review of these files revealed that patients incurred death and serious morbidity, and that several specific behavior errors accounted for the majority of patient injury. Among the damages that occurred during that time period were 88 deaths, 15 patients with profound brain damage, 15 patients who alleged that they had become addicted to medications prescribed for pain, 10 patients who required amputations of limbs, and 12 patients who suffered some degree of hearing loss or decreased visual acuity. The predominant categories where insureds incurred difficulty were in disregarding patient allergies to specific drugs (acetylsalicylic acid (aspirin), penicillin and its derivatives); prescribing drugs without consideration of the patient's medical history; failing to monitor therapy with anticoagulants, nonsteroidal anti-inflammatory drugs, digitalis derivatives, theophylline, and aminoglycoside antibiotics; antibiotic therapy; and errors in the writing of prescriptions. In order to reduce the number of patient injuries and accompanying medical malpractice suits from medication errors, the following suggestions are offered: 1. Heed the patient's warning regarding drug allergies and prescribe a substitute drug, especially if the drug is aspirin or penicillin (and derivatives) or if the patient gives a history of having asthma. If the patient gives a history of aspirin sensitivity, make certain the drug you are prescribing does not contain aspirin as one of its components. Often physicians stated that they were not aware that aspirin was contained in the drug they prescribed for patients with a documented allergy to aspirin.(ABSTRACT TRUNCATED AT 250 WORDS)

[Pathology of the nervous system caused by antibiotics as a manifestation of allergic vasculitis]. / Patologiia nervnoi sistemy, obuslovlennaia vozdeistviem antibiotikov, kak proiavleniem antibiotikov, kak proiavlenie allergicheskogo vaskulita.

The author studied the clinical picture and identified forms of neurological disorders in patients suffering from occupational diseases associated with their exposure to antibiotics. The following pathological forms were prevalent: diffuse damage to the nervous system (meningo-encephalo-myelo-polyradiculoneuritis), focal cerebral lesion, disseminated cerebral micro-symptoms, vegetovascular dystonia. It is concluded on the basis of clinical findings and data from clinical and physiological examination that neurological disturbances are an individual manifestation of systemic pathology with allergic vasculitis being the underlying cause.