Eliciting the barriers and enablers towards anaesthetists giving penicillin-based antibiotic prophylaxis to low-risk patients who have had their penicillin allergy label removed as part of a preoperative delabelling process.

Background: Some penicillin allergy labels can be removed by non-allergy specialists by direct oral challenge, but there is reluctance amongst anaesthetists to give penicillin to these patients. We aimed to assess anaesthetist beliefs about giving penicillin to patients delabelled by direct oral challenge. Methods: A survey, developed using the Theoretical Domains Framework, was circulated to anaesthetists within a regional research network in England. Domains were rated using 5-point Likert scales. Overall and group medians were used to dichotomize domains rated by group into 'relatively important/unimportant' and 'relative enabler/barrier'. Results: We received 257 responses from six hospitals (response rate 49.7%). Seven domains were rated as important for all stakeholder groups and hospitals: Knowledge, Skills, Belief in Capabilities, Belief in Consequences, Memory/Attention/Decisions, Environmental Context and Resources, and Emotions. Social and Professional Role was also important to all respondents except those in one hospital. Intentions and Optimism were rated as important for some groups/hospitals and unimportant for others. All four other domains were rated as unimportant for all groups/hospitals. All domains rated as important were enablers for all groups/hospitals, with the exception of Memory/Attention/Decisions and Emotions, which were rated as discordant barriers/enablers between groups. This means they were acting as a barrier for some staff groups/hospitals and an enabler for others. Barrier domains (Reinforcement, Goals, Social Influences, Behavioural Regulation) were all rated unimportant. Conclusions: Behavioural influences on giving penicillin prophylaxis to a delabelled patient are complex and nuanced. These findings could inform targeted interventions, both across and within hospitals and staff groups.

Non-allergist healthcare workers views on delivering a penicillin allergy de-labelling inpatient pathway: identifying the barriers and enablers.

Background: Non-allergist delivered PADL is supported by UK and World Health Organization guidelines but is not yet routine in UK hospitals. Understanding the views of healthcare workers (HCWs) on managing patients with penA records and exploring perspectives on delivering a PADL inpatient pathway are required to inform the development of non-allergist delivered PADL pathways. Objective: To explore the perspectives of non-allergist HCWs working in medical specialties on managing patients with penA records, and to explore the enablers and barriers to embedding PADL as a standard of care for inpatients. Methods: Semi-structured interviews with doctors, nurses, pharmacists and medicines optimization pharmacy technicians working in a district general hospital in the UK. Thematic analysis was used to analyse the data. Results: The PADL pathway was considered a shared responsibility of the multidisciplinary team, which needed to be structured and supported by a framework. PADL aligns with HCW roles but time to deliver PADL was a barrier. Training for HCWs on the benefits of PADL and delivering PADL for those patients where a penicillin might be beneficial during the current episode of care would both motivate HCWs to deliver PADL. Discussion and conclusion: The PADL pathway was acceptable to HCWs and aligned with their roles and current healthcare processes but their capacity to deliver PADL in a time pressured environment was a significant barrier.

Experiences of an inpatient penicillin allergy de-labelling pathway: capturing the patient voice.

Background: Non-allergist-delivered penicillin allergy de-labelling (PADL) is supported by UK and other national guidelines but is not yet routine practice in UK hospitals. Those who have undergone PADL report high rates of acceptance, but it is unknown why some continue to avoid penicillin, and why some decline testing. Objectives: To explore the experiences of patients recently approached for penicillin allergy (penA) assessment and de-label by non-allergists in a UK hospital to determine the barriers and enablers to patient acceptance of PADL. Methods: Qualitative study using semi-structured interviews with patients who were penA assessed and de-labelled during an inpatient stay between November 2022 and January 2023. Thematic analysis was used to analyse the data. Results: Nineteen patients were interviewed. Patients were largely unaware of the negative impact of penA on their healthcare. Patients had differing views on challenging their penA status while they were acutely unwell, some agreeing that it is the right time to test and others not. Patients declined testing because they felt they were at higher potential risk because they were older or had multiple comorbidities. Some patients who declined testing felt they would have been persuaded if they had received a better explanation of the risks and benefits of PADL. Conclusions: Patients who were successfully de-labelled were positive about the experience. Those who declined testing did so for a variety of reasons including frailty/comorbidities or a fear of testing whilst unwell. Patients highlighted the importance of good communication about the personalized risks and benefits of testing.

A multicentre observational study to investigate feasibility of a direct oral penicillin challenge in de-labelling 'low risk' patients with penicillin allergy by non-allergy healthcare professionals (SPACE study): Implications for healthcare systems.

OBJECTIVE: The huge burden of inaccurate penicillin allergy labels (PALs) is an important driver of antimicrobial resistance. This is magnified by insufficient allergy specialists and lack of 'point-of-care' tests. We investigated the feasibility of non-allergy healthcare professionals (HCPs) delivering direct oral penicillin challenges (DPCs) for penicillin allergy de-labelling. METHODS: This prospective observational study was conducted in three hospitals in England across three settings (acute medical, pre-surgical and haematology-oncology). Patients with a PAL were screened and stratified as low risk/high risk. Low risk patients (non-immune mediated symptoms, benign rash, tolerated amoxicillin since and family history) underwent a DPC. RESULTS: N = 2257 PALs were screened, 1054 were eligible; 643 were approached, 373 declined, 270 consented and 259 risk stratified (low risk = 155; high risk = 104). One hundred and twenty-six low risk patients underwent DPC, 122 (96.8%) were de-labelled with no serious allergic reactions. Conversion rate from screening-to-consent was 12% [3.3% and 17.9% in acute and elective settings respectively; odds ratios for consent were 3.42 (p < 0.001) and 5.53 (p < 0.001) in haematology-oncology and pre-surgical setting respectively. Common reasons for failure to progress in the study included difficulty in reaching patients, clinical instability/medical reasons, lacking capacity to consent and psychological factors. INTERPRETATION: DPCs can be delivered by non-allergy HCPs. A high proportion of patients with PALs did not progress in the study pathway. Strategies to deliver DPC at optimal points of the care pathway are needed to enhance uptake. Elective settings offer greater opportunities than acute settings for DPC. The safety and simplicity of DPCs lends itself to adoption by healthcare systems beyond the UK, including in resource-limited settings.

Penicillin allergy de-labelling by non-allergists: a comparison of testing protocols.

Optimizing penicillin allergy de-labelling (PADL) to ensure patients with an incorrect penicillin allergy record are de-labelled with minimal patient harm is important for antibiotic stewardship. The heterogeneity of inclusion and exclusion criteria in the published penicillin allergy testing protocols risks suboptimal delivery of PADL. We compared the similarities and the differences between non-allergist-delivered PADL testing protocols and make suggestions for harmonization. The observed variation in testing practice has two broad elements: (i) definitions and terminology; and (ii) differences in the acceptability of perceived risk. All direct drug provocation testing (DDPT) protocols included patients with benign delayed rash as eligible for testing, although the remoteness of the rash, and the terminology used to describe the rash, differed. Patients with features of potential IgE reactions were excluded from most DDPT protocols, but not all of them. There was differing advice on how to manage patients who had subsequently tolerated penicillin since the index reaction and differences in which patients were considered ineligible for DDPT due to acuity of illness, comorbidities and concomitant medications. Standardization of the terminology used in penicillin allergy testing protocols and consensus on inclusion and exclusion criteria are required for safe and efficient PADL delivery at scale by non-allergists.

Developing a model for decision-making around antibiotic prescribing for patients with COVID-19 pneumonia in acute NHS hospitals during the first wave of the COVID-19 pandemic: qualitative results from the Procalcitonin Evaluation of Antibiotic use in COVID-19 Hospitalised patients (PEACH Study).

OBJECTIVE: To explore and model factors affecting antibiotic prescribing decision-making early in the pandemic. DESIGN: Semistructured qualitative interview study. SETTING: National Health Service (NHS) trusts/health boards in England and Wales. PARTICIPANTS: Clinicians from NHS trusts/health boards in England and Wales. METHOD: Individual semistructured interviews were conducted with clinicians in six NHS trusts/health boards in England and Wales as part of the Procalcitonin Evaluation of Antibiotic use in COVID-19 Hospitalised patients study, a wider study that included statistical analysis of procalcitonin (PCT) use in hospitals during the first wave of the pandemic. Thematic analysis was used to identify key factors influencing antibiotic prescribing decisions for patients with COVID-19 pneumonia during the first wave of the pandemic (March to May 2020), including how much influence PCT test results had on these decisions. RESULTS: During the first wave of the pandemic, recommendations to prescribe antibiotics for patients with COVID-19 pneumonia were based on concerns about secondary bacterial infections. However, as clinicians gained more experience with COVID-19, they reported increasing confidence in their ability to distinguish between symptoms and signs caused by SARS-CoV-2 viral infection alone, and secondary bacterial infections. Antibiotic prescribing decisions were influenced by factors such as clinician experience, confidence, senior support, situational factors and organisational influences. A decision-making model was developed. CONCLUSION: This study provides insight into the decision-making process around antibiotic prescribing for patients with COVID-19 pneumonia during the first wave of the pandemic. The importance of clinician experience and of senior review of decisions as factors in optimising antibiotic stewardship is highlighted. In addition, situational and organisational factors were identified that could be optimised. The model presented in the study can be used as a tool to aid understanding of the complexity of the decision-making process around antibiotic prescribing and planning antimicrobial stewardship support in the context of a pandemic. TRIAL REGISTRATION NUMBER: ISRCTN66682918.

Removal of incorrect penicillin allergy labels in a UK hospital.

OBJECTIVES: Penicillin allergy records are common, often incorrect and are associated with broad spectrum antibiotic use. We piloted a pharmacist-led multidisciplinary penicillin allergy de-labelling daily ward round to determine the opportunity for penicillin allergy de-labelling in a UK hospital. METHODS: A daily ward round, delivered by antibiotic pharmacists or junior doctors, identified adult medical and surgical patients between 7 November 2022 and 31 January 2023 with a penicillin allergy record that was preventing first-line penicillin use. An allergy history was taken before risk stratifying likelihood of future harm from penicillin re-exposure and an allergy testing method was determined (direct de-label on history alone or after direct drug provocation testing). After successful allergy de-label, the antibiotic was switched to a penicillin antibiotic. RESULTS: Of 7214 inpatients during the study period, 1133 (15.7%) had a penicillin allergy record. Of 285 allergy histories taken, 105 (36.8%) met high-risk criteria, 45 (15.8%) met low-risk criteria eligible for direct de-label and 73 (25.6%) met criteria eligible for direct drug provocation testing. We were unable to obtain a history for 61 (21.4%) patients. Of 45 low-risk patients eligible for direct de-label, 40 (88.9%) were de-labelled of whom 24 (53.3%) were switched to a penicillin antibiotic. Of 73 patients with a low-risk allergy history eligible for direct drug provocation testing, 16 (21.9%) received direct drug provocation testing, of whom 9 were switched to a penicillin antibiotic. Two direct de-label patients experienced harm (thrush within 5 days and delayed skin reaction after day 5); none of the direct drug provocation testing patients had a reaction by day 5. The switches resulted in reduced alternative antibiotic use by 173 Daily Defined Doses (DDDs). DISCUSSION: Penicillin allergy de-labelling patient pathway delivered by pharmacists and junior doctors was safe and effective and well accepted by patients and the wider clinical teams.

Geoforensic search to crime scene: Remote sensing, geophysics, and dogs.

In the absence of surface indications of burial sites, law enforcement or humanitarian organizations are faced with the difficult task of focusing large-scale ground searches to a manageable excavation area. A geoforensic-based survey may exclude parts of the landscape for reasons such as diggability or viewshed analysis but leave areas still too large for invasive exploration. This work examines how drone-based remote sensing, geophysics, and search dogs may be combined to narrow such searches. Here, we ask the reader to consider two examples where forensic geomorphology and land use provided a range of possible burial locations. Following this is a multi-proxy approach to similar dilemma, with a search-to-scene case study using remote sensing (drone photography), geophysics, ground probes, and search dogs. This approach is not presented as a definitive guide, but serves as an example of the conjunctive use of well-studied methods to approach a common problem in geoforensics.

Assessment of the appropriateness of antibiotic prescribing in an acute UK hospital using a national audit tool: a single centre retrospective survey.

INTRODUCTION: Antibiotic use drives antibiotic resistance. The UK antimicrobial resistance (AMR) strategy aims to reduce antibiotic use. We aimed to quantify excess antibiotic use in a district general hospital in south-west England. METHODS: Medical patients discharged in August 2020 who had received antibiotics were included. An audit tool of antibiotic prescribing appropriateness was used to collect relevant clinical information regarding each patient case. The appropriateness of antibiotic use was then determined by two infection specialists and excess days of therapy (DOTs) calculated. RESULTS: 647 patients were discharged in August 2020. Of the 1658 antibiotic DOTs for the 184 patients reviewed, 403 (24%) were excess DOTs. The excess antibiotic DOTs were prescribed in 92 patients (50%); 112/403 (27.8%) excess DOTs originated at the initiation of antibiotic therapy (time point A); 184/403 (45.7%) of excess DOTs occurred at the antibiotic review pre-72 hours (time point B); and 107/403 (26.6%) of excess DOTs were due to protracted antibiotic courses (time point C). CONCLUSION: 24% of antibiotic DOTs were deemed unnecessary. The greatest opportunity to reduce antibiotic use safely was the pre-72 hours antibiotic review, which may provide a target for reducing excess antimicrobial therapy in line with the national AMR strategy.

Addressing the Challenges of Penicillin Allergy Delabeling With Electronic Health Records and Mobile Applications.

Allergy labels are common, often incorrect, and potentially harmful. There are many opportunities for clinical decision support (CDS) tools integrated in the electronic health record (EHR) and mobile apps to address the challenges with drug allergy management, including penicillin allergy delabeling (PADL). Effective delabeling solutions must consider multidisciplinary clinical workflow and multistep processes, including documentation, assessment, plan (eg, allergy testing and referral), record update, drug allergy alert management, and allergy reconciliation over time. Developing a systematic infrastructure to manage allergies across the EHR is critical to improve the accuracy and completeness of a patient's allergy and avoid inadvertently relabeling. Improving the appropriateness and relevancy of drug allergy alerts is important to reduce alert fatigue. Using alerts to guide clinicians on appropriate antibiotic use may reduce unnecessary ß-lactam avoidance. To date, EHR CDS tools have facilitated non-allergists to provide PADL at the point of care. A mobile app was shown to support PADL and provide specialist support and education. Future research is needed to standardize, integrate, and evaluate innovative CDS tools in the EHR to demonstrate patient safety and clinical utility and facilitate wider adoption.

The effectiveness of interventions that support penicillin allergy assessment and delabeling of adult and pediatric patients by nonallergy specialists: a systematic review and meta-analysis.

OBJECTIVES: Penicillin allergy records are often incorrect and may result in harm. We aimed to systematically review the effectiveness and safety of nonallergist health care worker delivery of penicillin allergy delabeling. METHODS: We searched EMBASE/MEDLINE/CINAHL (Ovid), PsycInfo, Web of Science, and Cochrane CENTRAL from inception to January 21, 2022 and unpublished studies and gray literature. The proportion of patients allergic to penicillin delabeled and harmed was calculated using random-effects models. RESULTS: Overall, 5019 patients were delabeled. Using allergy history alone, 14% (95% confidence interval [CI], 9-21%) of 4350 assessed patients were delabeled without reported harm. Direct drug provocation testing resulted in delabeling in 27% (95% CI, 18-37%) of 4207 assessed patients. Of the 1373 patients tested, 98% were delabeled (95% CI, 97-99%), and nonserious harm was reported in 1% (95% CI, 0-2%). Using skin testing, followed by drug provocation testing, 41% (95% CI, 24-59%) of 2890 assessed patients were delabeled. Of the 1294 tested patients, 95.0% (95% CI, 90-99%) were delabeled, and the reported harm was low (0%; (95% CI 0-1%). CONCLUSION: Penicillin allergy delabeling by nonallergists is efficacious and safe. The proportion of assessed patients who can be delabeled increases with the complexity of testing method, but substantial numbers can be delabeled without skin testing.

Antibiotic review kit for hospitals (ARK-Hospital): a stepped-wedge cluster-randomised controlled trial.

BACKGROUND: Strategies to reduce antibiotic overuse in hospitals depend on prescribers taking decisions to stop unnecessary antibiotic use. There is scarce evidence for how to support these decisions. We evaluated a multifaceted behaviour change intervention (ie, the antibiotic review kit) designed to reduce antibiotic use among adult acute general medical inpatients by increasing appropriate decisions to stop antibiotics at clinical review. METHODS: We performed a stepped-wedge, cluster (hospital)-randomised controlled trial using computer-generated sequence randomisation of eligible hospitals in seven calendar-time blocks in the UK. Hospitals were eligible for inclusion if they admitted adult non-elective general or medical inpatients, had a local representative to champion the intervention, and could provide the required study data. Hospital clusters were randomised to an implementation date occurring at 1-2 week intervals, and the date was concealed until 12 weeks before implementation, when local preparations were designed to start. The intervention effect was assessed using data from pseudonymised routine electronic health records, ward-level antibiotic dispensing, Clostridioides difficile tests, prescription audits, and an implementation process evaluation. Co-primary outcomes were monthly antibiotic defined daily doses per adult acute general medical admission (hospital-level, superiority) and all-cause mortality within 30 days of admission (patient level, non-inferiority margin of 5%). Outcomes were assessed in the modified intention-to-treat population (ie, excluding sites that withdrew before implementation). Intervention effects were assessed by use of interrupted time series analyses within each site, estimating overall effects through random-effects meta-analysis, with heterogeneity across prespecified potential modifiers assessed by use of meta-regression. This trial is completed and is registered with ISRCTN, ISRCTN12674243. FINDINGS: 58 hospital organisations expressed an interest in participating. Three pilot sites implemented the intervention between Sept 25 and Nov 20, 2017. 43 further sites were randomised to implement the intervention between Feb 12, 2018, and July 1, 2019, and seven sites withdrew before implementation. 39 sites were followed up for at least 14 months. Adjusted estimates showed reductions in total antibiotic defined daily doses per acute general medical admission (-4·8% per year, 95% CI -9·1 to -0·2) following the intervention. Among 7 160 421 acute general medical admissions, the ARK intervention was associated with an immediate change of -2·7% (95% CI -5·7 to 0·3) and sustained change of 3·0% (-0·1 to 6·2) in adjusted 30-day mortality. INTERPRETATION: The antibiotic review kit intervention resulted in sustained reductions in antibiotic use among adult acute general medical inpatients. The weak, inconsistent intervention effects on mortality are probably explained by the onset of the COVID-19 pandemic. Hospitals should use the antibiotic review kit to reduce antibiotic overuse. FUNDING: UK National Institute for Health and Care Research.

Procalcitonin Evaluation of Antibiotic Use in COVID-19 Hospitalised Patients (PEACH): Protocol for a Retrospective Observational Study.

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is a novel virus responsible for the coronavirus disease 2019 (COVID-19) pandemic. Although COVID-19 is a viral illness, many patients admitted to hospital are prescribed antibiotics, based on concerns that COVID-19 patients may experience secondary bacterial infections, and the assumption that they may respond well to antibiotic therapy. This has led to an increase in antibiotic use for some hospitalised patients at a time when accumulating antibiotic resistance is a major global threat to health. Procalcitonin (PCT) is an inflammatory marker measured in blood samples and widely recommended to help diagnose bacterial infections and guide antibiotic treatment. The PEACH study will compare patient outcomes from English and Welsh hospitals that used PCT testing during the first wave of the COVID-19 pandemic with those from hospitals not using PCT. It will help to determine whether, and how, PCT testing should be used in the NHS in future waves of COVID-19 to protect patients from antibiotic overuse. PEACH is a retrospective observational cohort study using patient-level clinical data from acute hospital Trusts and Health Boards in England and Wales. The primary objective is to measure the difference in antibiotic use between COVID-19 patients who did or did not have PCT testing at the time of diagnosis. Secondary objectives include measuring differences in length of stay, mortality, intensive care unit admission, and resistant bacterial infections between these groups.

Implementation of the Antimicrobial Review Kit (ARK) to optimise antimicrobial prescribing at the Royal Cornwall Hospital: a behavioural change odyssey.

Antibiotic use drives antimicrobial resistance (AMR). The Antimicrobial Review Kit (ARK) study is a complex intervention based on national antibiotic stewardship guidance. We describe the implementation of ARK at a 760-bed teaching hospital that uses electronic prescribing. An online education module was disseminated to healthcare workers, and the ARK decision tool was incorporated into the medical clerking pro forma. From July 2018, junior doctors audited the frequency, the outcomes of pre-72-hour antibiotic reviews and the use of the ARK tool. The data were used to formulate specialty-level feedback and bench marking. First-phase data were plotted on statistical process control (SPC) charts to distinguish between common and special cause variation. There was significant improvement in antibiotic review rates (81% to 93%) and stop rates (10% to 15%). The stop rate reached 25% in the most recent data. Given the promising trends, it may be possible to achieve the target stop rate of 30%.

Identification of Intervention Opportunities through Assessment of the Appropriateness of Antibiotic Prescribing in Surgical Patients in a UK Hospital Using a National Audit Tool: A Single Centre Retrospective Audit.

Identifying opportunities to safely reduce antibiotic prescribing is necessary for prescribers and antibiotic stewardship teams to minimise unwarranted antibiotic use. We aimed to quantify excess antibiotic use in General Surgery. We retrospectively audited the antibiotic prescribing for patients discharged from the General Surgery specialty in an acute hospital in the south-west of England for one month using an audit tool developed by Public Health England. The appropriateness of prescribing was determined for each patient at three antibiotic decision time-points: at initiation, the pre-72-hour antibiotic review, and treatment duration. Two infection specialists and a general surgeon reviewed each patient. Indication and excess days of therapy (DOTs) were calculated at each decision time-point and expressed as a proportion of total DOTs. Eighty-six patients were prescribed 1162 DOTs; 192 (16.5%) excess DOTs were prescribed in 38 patients (44%), with zero excess days identified in the remaining 48 patients (56%). Seventy-five of 192 (39%) excess DOTs occurred at initiation; 55/192 (29%) after the pre-72-hour antibiotic review; and 62/192 (32%) due to protracted antibiotic courses. There was concordance between the general surgeon and infection specialist for most apportioned excess DOTs. However, the surgeon apportioned fewer excess DOTs 160/1162 (13.8%). Overall IV antibiotics accounted for 53.4% of total DOTs. Seventy-two of 86 (83.7%) patients received 620 intravenous DOTs; of these, 79 (12.7%) IV DOTS were unnecessary. We have identified excess antibiotic prescribing in General surgery with comparable excess DOTs at all three time-points.

Impact of introducing procalcitonin testing on antibiotic usage in acute NHS hospitals during the first wave of COVID-19 in the UK: a controlled interrupted time series analysis of organization-level data.

BACKGROUND: Blood biomarkers have the potential to help identify COVID-19 patients with bacterial coinfection in whom antibiotics are indicated. During the COVID-19 pandemic, procalcitonin testing was widely introduced at hospitals in the UK to guide antibiotic prescribing. We have determined the impact of this on hospital-level antibiotic consumption. METHODS: We conducted a retrospective, controlled interrupted time series analysis of organization-level data describing antibiotic dispensing, hospital activity and procalcitonin testing for acute hospitals/hospital trusts in England and Wales during the first wave of COVID-19 (24 February to 5 July 2020). RESULTS: In the main analysis of 105 hospitals in England, introduction of procalcitonin testing in emergency departments/acute medical admission units was associated with a statistically significant decrease in total antibiotic use of -1.08 (95% CI: -1.81 to -0.36) DDDs of antibiotic per admission per week per trust. This effect was then lost at a rate of 0.05 (95% CI: 0.02-0.08) DDDs per admission per week. Similar results were found specifically for first-line antibiotics for community-acquired pneumonia and for COVID-19 admissions rather than all admissions. Introduction of procalcitonin in the ICU setting was not associated with any significant change in antibiotic use. CONCLUSIONS: At hospitals where procalcitonin testing was introduced in emergency departments/acute medical units this was associated with an initial, but unsustained, reduction in antibiotic use. Further research should establish the patient-level impact of procalcitonin testing in this population and understand its potential for clinical effectiveness.