TY - JOUR
AU - Dreskin, Stephen, C.
AB - Abstract Purpose Patient safety improvements and increased efficiencies achieved through the establishment of standardized protocols and order sets for selected antibiotic desensitization procedures are described. Summary Errors in the ordering and administration of antimicrobial desensitization regimens can result in life-threatening complications. To enhance patient safety, the University of Colorado Hospital pharmacy department worked with allergy and immunology physicians (AIPs) to implement standardized desensitization protocols to reduce the potential for confusion surrounding the prescribing and administration of these complex regimens to acutely ill populations such as patients with cystic fibrosis, as many as 30% of whom develop one or more antimicrobial allergies. Nine i.v. antibiotics were identified as suitable for the standardization initiative; based on AIP experience and published guidelines, therapeutic doses of each targeted medication were determined. For each of the nine drugs, the interdisciplinary team developed an instruction sheet on preparing stock concentrations and compounding sequential doses for desensitization, with a corresponding preprinted order set detailing infusion procedures, monitoring requirements, guidance on the use of rescue medications and other steps for managing adverse reactions, and patient safeguards. Initial experience with the standardized protocols indicated that relative to previous practices (i.e., physician submission of handwritten patient-specific orders, with pharmacist calculation of required dilutions case by case), the standardization initiative (1) reduced the potential for errors, (2) sharply reduced order-entry and product preparation times, and (3) helped achieve antimicrobial stewardship goals. Conclusion Standardized antimicrobial desensitization protocols helped to optimize patient care and antimicrobial stewardship while enabling more efficient use of pharmacy and AIP resources and fostering enhanced pharmacist–physician collaboration. Am J Health-Syst Pharm 2013;70:540–8 Desensitization is the process of administering an offending medication to a patient identified as having an allergy to the medication. This process starts with the administration of very small doses of the offending medication and incrementally progresses to larger, therapeutic doses.1,–5 Medication allergies can pose a challenge for the clinician seeking to choose a medication regimen that best fits a patient’s clinical needs. Selecting an optimal antimicrobial regimen can be particularly vexing, as numerous pharmacodynamic and pharmacokinetic factors, the site of infection, and pathogen susceptibilities warrant careful consideration. Added to these issues, an antibiotic allergy can decidedly narrow the choice of agent(s). A past allergic reaction to an antibiotic can effectively disqualify not only that agent but also the entire antibiotic class—and possibly even related classes of antimicrobial agents—from an already limited list of therapeutic options. In an acute care setting, these limitations also make it difficult to optimally employ antimicrobial stewardship, which is beneficial not only to the individual but to the entire institutional setting, by limiting or directing the selective pressures of antimicrobial prescriptions.6 The goal of antibiotic desensitization is to allow the safe administration of an offending antibiotic in a timely fashion. Antibiotic desensitization procedures are complicated. The processes the medications used in desensitization are time-consuming and can be prone to errors when orders are not uniformly written, medications are not uniformly prepared, or doses are not administered in the proper sequential fashion. Errors during the desensitization process can potentially result in life-threatening reactions. To address those and other challenges, about three years ago the University of Colorado Hospital (UCH) department of pharmacy and the hospital’s allergy and immunology physicians (AIPs) collaborated to establish standardized order templates for several antiinfective medications. UCH is a 430-bed academic medical center in the Rocky Mountain region that is active in burn management, solid-organ and bone marrow transplantation, critical care medicine, and surgery, as well as a full complement of medical–surgical and ambulatory care services. Through its lung transplantation program, UCH serves as a primary center of lung transplantation medicine and surgery for patients with cystic fibrosis (CF) and other patients of National Jewish Health, a UCH-affiliated institution. Problem As many as 30% of patients with CF develop allergies to one or more antimicrobial agents, most commonly the penicillin class.2 These patients’ extensive exposure to antimicrobials can also select for multidrug-resistant organisms such as Burkholderia cepacia and Pseudomonas aeruginosa presenting as colonizers and pathogens. As there are few antibiotics with demonstrated activity against these organisms, it is very difficult to effectively treat infected patients even under the best of circumstances; further limitations are presented if they have antibiotic allergies. Immediate hypersensitivity reactions result from the prior production of immunoglobulin E (IgE) antibodies to an offending agent (i.e., an antigen) and the binding of IgE to mast cells. On reexposure to the antigen, the release of mediators from mast cells can cause a broad range of allergic responses, from mild to severe.7,8 Mild reactions are defined as itching, urticaria, nasal congestion, mild dyspnea, and wheezing. Severe reactions are characterized by anaphylaxis, laryngospasm, and persistent stridor, wheezing, and hypotension.9 In addition to pulmonologists specializing in CF management, the UCH antimicrobial stewardship team (AST) provides support for antimicrobial selection in all difficult-to-treat patient populations. The AST performs prospective surveillance of daily antibiotic use and plans to publish the UCH antibiogram’s first combination-activity report, aimed specifically at P. aeruginosa susceptibilities. The new report will make available to UCH providers valuable information on the activities of selected antipseudomonal β-lactams used as monotherapies, as well as comparative data on their use in combination with other antipseudomonal classes such as the fluoroquinolone and aminoglycoside agents. This reporting initiative is a multidisciplinary effort aiming to provide in-house evidence-based information supporting (or, as appropriate, refuting) the use of combination therapy. In treating patients with CF as well as others with antibiotic allergies, in many cases it is apparent that the best antimicrobial is an agent within the class of agents to which the patient is thought to be allergic. In the setting of an acute illness, it is not practical to definitively establish the presence of a clinically relevant allergy. Given the high acuity level of our patient population and given that allergy and immunology care is a special focus of UCH services, i.v. and oral antibiotic desensitizations are regularly performed. When the desensitization and reporting process described in this article was implemented, UCH did not have computerized prescriber order entry (CPOE). Before the implementation of standardized, preprinted desensitization orders, desensitizations were performed, but physicians handwrote patient-specific orders, and the pharmacy department calculated dilutions for each order and compounded the doses needed for the desensitization. Such individualized desensitization procedures were prone to result in medication errors, especially when either orders or the medication administration process was not uniformly completed. Particularly in patients with CF, these errors can pose potentially life-threatening reactions. Analysis and resolution To enhance patient safety by reducing potential confusion regarding the preparation of desensitization doses and their sequential administration and to decrease the turnaround time from product preparation to administration at the patient’s bedside, desensitization order sets and the desensitization process were standardized using an established protocol to direct the selection, preparation, and administration of nine commonly used antibiotics. Antibiotic desensitization may be performed when the patient has a presumed allergy involving an IgE-mediated hypersensitivity to a needed treatment option with activity against the targeted pathogen.3 At UCH, patients undergoing desensitization are usually admitted to the intensive care unit (ICU) before starting the desensitization process due to the risk of life-threatening hypersensitivity reactions. Intravenous medications commonly used for desensitization at UCH, including several antipseudomonal agents, were identified based on the clinical experience of the hospital’s AIPs. Nine i.v. antimicrobials were considered suitable for compounding for use in standardized desensitizations. Final therapeutic doses of each medication were determined; subsequently, based on published literature, smaller doses were established using 10-fold dilutions, with a smaller increment of dilution used to prepare the highest two doses.1,–5 For the smaller doses, each medication required approximately 10–15 dilutions before the desired final therapeutic dose was achieved. A standardized desensitization order set should (1) enhance patient safety, (2) reduce confusion regarding concentrations and dilutions during preparation and administration of desensitization, (3) decrease product turnaround time, and (4) optimize antimicrobial stewardship and patient care by giving clinicians the ability to administer first-line antiinfective agents rather than alternative regimens. The approval of several hospital committees and the departments of all practitioners involved in the process was required for the development and implementation of the new desensitization protocols. Protocol development was conducted in a stepwise fashion, as described below. Securing institutional support. A critical first step was receiving multidisciplinary agreement and committee approval of a policy that supported the use of the standardized desensitization templates. The policy (and, later, the proposed order sets) were peer reviewed by AIPs, the infectious diseases and critical care medicine services, and the pharmacy and nursing departments. Throughout the protocol development process, the concerns and suggestions of practitioners on issues such as the location where desensitization can be performed were entertained; any revisions to the protocol and the corresponding order set were subject to peer review and approval. The revised protocol was then presented to and reviewed by several multidisciplinary committees, including the antimicrobial stewardship committee, the formulary subcommittee, the pharmacy and therapeutics committee, the policy and procedure subcommittee, and the forms committee, as well as nursing educators. The finalized protocols and order sets were made available for use by UCH providers approximately 20 months after the protocol development process was initiated. Antibiotic selection. Medications that are commonly used for desensitization at UCH were identified based on the clinical experience of AIPs as well as the antibiotic needs of our patient population. Nine i.v. antibiotics were identified for standardization: ampicillin, cefepime, ceftazidime, doripenem, imipenem, meropenem, nafcillin, penicillin, and piperacillin–tazobactam. Because of UCH’s substantial CF population, it was not surprising that six of the nine agents are antipseudomonal antiinfectives. Derivation of desensitization dosing. When determining desensitization doses, the desired final therapeutic doses, including those used for dialysis dosing, were identified for each medication. Then, through 10fold dilutions, the smaller desensitization doses were established. Each medication required approximately 10–15 dilutions before reaching the desired final therapeutic dose of each of the nine antimicrobial agents. The penultimate dose usually entails a 3- to 5-fold, rather than a 10-fold, increase from the prior and subsequent doses.1,–4 Alternative protocols calling for higher initial doses followed by smaller incremental increases have been published.5 Establishing preprinted order sets. The escalating desensitization doses and the final scheduled full therapeutic dose of antibiotic to be administered after the completion of the desensitization process were established and incorporated into preprinted order sets for each specific medication (Figure 1). To reduce the total amount of i.v. fluids a patient received during desensitization, each dose was admixed with 50 mL of 0.9% sodium chloride injection (unless compatibility or concentration limitations required a different solution or volume). The monitoring requirements, detailed descriptions of adverse-reaction severity categories, and the medications used for adverse-reaction management were also included on the order set. Figure 1. Open in new tabDownload slide Open in new tabDownload slide Example of preprinted order set for antimicrobial desensitization. ICU = intensive care unit, CF = cystic fibrosis. Figure 1. Open in new tabDownload slide Open in new tabDownload slide Example of preprinted order set for antimicrobial desensitization. ICU = intensive care unit, CF = cystic fibrosis. Establishing standardized compounding formulas. Once desensitization dosing was finalized for each of the nine selected agents and approved by AIPs, the pharmacy service developed corresponding preparation instruction sheets for each agent. Included on the instruction sheets were the starting vial size of the antimicrobial to be used and instructions for the initial dilution. These compounding instructions further delineated the desired serial dilutions and aliquots for the series of doses required for desensitization. After dilution and dose calculations were established, the compounding instructions were peer reviewed and approved for use, eliminating the need to obtain prescribers’ specific approval of each desensitization preparation. These compounding instruction sheets (Figure 2) were made readily accessible to all pharmacy personnel on the pharmacy department’s shared network drive. Figure 2. Open in new tabDownload slide Instruction sheet on preparing ceftazidime for use in desensitization. SWI = sterile water for injection, D5W = 5% dextrose injection. Figure 2. Open in new tabDownload slide Instruction sheet on preparing ceftazidime for use in desensitization. SWI = sterile water for injection, D5W = 5% dextrose injection. Protocol description. As the order sets were prepared, a standardized protocol for i.v. desensitization was developed. The protocol describes prescribing restrictions, “relative” and “strong relative” contraindications to desensitization, the need to obtain the patient’s signed consent, administration instructions, adverse-reaction severity descriptions, and medications for managing adverse reactions. The protocol stresses that the patient is only transiently desensitized to the agent being administered and is still classified as allergic to that agent. Educational efforts. Following committee approval and before protocol implementation, educational inservice programs were performed for the staffs of all hospital services that would be directly or peripherally involved with some aspect of the desensitization process. Written and oral education were provided to pharmacists, pharmacy technicians, nursing staff, and AIPs, as well as CF specialists and infectious diseases and critical care physicians. Initial experience with the protocols. We believe that the standardized order sets have enhanced patient safety by reducing the risk of inaccurate interpretation of handwritten orders. Further, they have eliminated a wide variety of prescribed drug concentrations written by multiple prescribers. A query of resident and attending AIPs conducted before the standardization initiative demonstrated that the time to prepare handwritten orders for desensitizations typically ranged from 20 to 60 minutes; the variation in time requirements mostly correlated with prescriber experience. In contrast, the standardized order sets are typically completed in less than 5 minutes. In addition, the standardization of order set doses exactly matches the pharmacy-developed, drug-specific order-entry protocols in the pharmacy computer system; this has reduced preparation errors in the i.v. compounding room, as the calculated serial dilutions are now performed according to standardized pharmacy compounding sheets. Moreover, the streamlined preparation instructions have improved pharmacist and technician familiarity with the standardized compounding process, as there is now one specified method of preparing the dilutional doses. Before standardization, a pharmacist calculated patient-specific dilutions and doses in accordance with each prescriber’s order, and a second pharmacist double-checked the calculations before order entry, a process that could take one to four hours depending on the workload of the pharmacist. With a standardized process for physicians and pharmacy staff, the product turnaround time has been dramatically reduced; most antibiotic desensitizations are now prepared in 30–60 minutes. Interdisciplinary patient care. In addition to standardizing a complex process, the standardization project has enhanced interdisciplinary relationships. Physicians who prescribe desensitization procedures, such as AIPs and CF specialists, have developed a better understanding of the complexity of pharmacy preparation of desensitization orders. As a result, providers now tend to give the pharmacy advance notification of forthcoming desensitization orders, oftentimes giving the pharmacy staff 12 or more hours to prepare doses. Advance notification has also enhanced nursing staff preparation for desensitization procedures (e.g., through shift scheduling), which require in-depth and frequent nursing monitoring. Likewise, communication and coordination with pertinent clinics have increased in order to facilitate hospital admissions solely for desensitizations. Prescribing practices. Before the implementation of the standardized protocol, only AIPs prescribed desensitization procedures at UCH. The new protocol allows infectious diseases, ICU, CF, and lung transplant physicians to prescribe desensitization after patient-specific recommendations from an AIP for desensitization of non-naive patients (i.e., those who have previously undergone a drug-specific desensitization to a medication to which they are allergic without complication). Despite standardization, when desensitizing naive patients, the responsible AIP must prescribe the desensitization and be present during the first infusion. Standardization of desensitizations has increased the safety of prescribing and AIPs’ efficiency. With the prescribing of desensitization procedures for non-naive patients expanded to include services other than the allergy and immunology service, the limited AIP service resources can be devoted to allergy and immunology clinics and other UCH service areas. It also allows for physicians who are not AIPs to become more involved in their patients’ comprehensive care. Each of the desensitization order sets also includes medications and instructions for the management of adverse events, should they occur. Standardization of desensitization has enhanced interdisciplinary collaboration to provide patients with efficient care, reduced the time spent on writing and preparing desensitization orders, and increased the availability of AIPs for other clinical duties. The standardization of nine antibiotic desensitization regimens has been well tolerated by patients receiving the regimens and has resulted in reduced preparation time spent by pharmacists and decreased ICU length of stay; the initiative also has been well received by staff. During the first eight months after the implementation of standardized desensitization orders, 11 patients underwent desensitization. All of these desensitizations were deemed successful, as all desensitization doses were administered. An illustrative patient case. As an example of the benefits of standardization, consider the case of a 48-year-old woman admitted to UCH for the treatment of an exacerbation of CF before the standardization of the desensitization order sets and written protocol. An AIP was consulted and prescribed a ceftazidime desensitization regimen. After receiving the orders, the amount of pharmacist order-entry time for the desensitization doses was 2.6 hours. The patient was successfully desensitized to ceftazidime (despite requiring the use of diphenhydramine and epinephrine for facial and chest flushing during the administration of the ninth dose). The patient spent 45 hours in the ICU (as determined by reviewing the times that orders to transfer the patient into and out of the ICU were written). On a subsequent hospital visit by the same patient, a repeat desensitization to ceftazidime was required, and the standardized desensitization protocol was used. With the use of the protocol, pharmacist order-entry time for the desensitization doses was about 30 minutes; thus, when compared with the patient’s initial desensitization procedure, standardization saved over 2 hours of pharmacist time. The repeat desensitization was successful and well tolerated (i.e., the patient did not require medications to manage adverse reactions). The patient’s length of stay in the ICU during the second desensitization procedure was 39 hours—6 hours less than during the initial desensitization. Discussion Multidrug-resistant pathogens are increasingly prevalent while the armamentarium of available effective antimicrobials is diminishing. Antibiotic desensitization is a strategy that can be employed to offer patients with antibiotic allergies the most active antiinfective agent available. This is preferable to patients receiving second-line or other alternative agents due to limitations posed by their allergies, which can severely narrow the therapeutic options.10 The preparation of each of the nine i.v. antimicrobials selected for desensitization protocol standardization is a complex process that begins with their prescription and extends through the compounding of as many as 15 sequential doses and their successive administration to the patient in progressively larger doses until the therapeutic dose is attained and continued. Before the desensitization protocol was implemented, the lack of a standardized order set necessitated the use of handwritten prescriptions from multiple physicians, increasing opportunities for errors by all services involved in the desensitization process. The protocol clearly outlines the appropriate procedures when administering desensitization. To reduce the potential for medication errors, the protocol emphatically states that the infusions are to be administered first with the numbered smallest dose, with the strength of each subsequent dose increased until attainment of the therapeutic dose. It is of critical importance to note that despite undergoing desensitization, a patient is still considered to be allergic to the offending medication; without constant exposure to that agent, antigen-specific mast cells will redevelop and the patient is at risk for an allergic reaction with future exposure. Moreover, if the patient requires treatment with the agent again, repeat desensitization will be required. To help ensure patient safety, the protocol specifies that desensitization must take place in an ICU setting, that an AIP must be present during the administration of the first dose to a desensitization-naive patient, and that the patient must have a regularly scheduled medication ordered to follow the desensitization procedure. Unless otherwise determined by the responsible AIP, desensitization may need to be repeated if the protocol is interrupted for greater than one hour or if, after initial desensitization, three doses of the regularly scheduled medication are missed. Some institutions are able to perform desensitizations as “Friday afternoon” procedures, as dictated by bed availability, or to perform the procedures electively. Unfortunately, UCH has not been able to perform desensitizations under such circumstances. Despite the opening of a new, larger inpatient pavilion only five years ago, UCH has consistently operated at 110–115% of bed capacity; this strain is anticipated to ease somewhat in 2013 with the broadening of the hospital’s ICU bed capacity to include part of a newly constructed 287-bed tower. Also, the abrupt transition of certain patient populations from inpatient to outpatient status, or vice versa, dictates that many desensitizations be performed very quickly on an as-needed basis. Relative contraindications to desensitization include a poorly documented history of drug allergy and concurrent β-blocker use.5,10 If the history is not consistent with a previous allergic reaction to a particular agent, clinicians are advised to consider giving the drug directly or administering a test dose of the drug in a controlled setting. If the patient is receiving a β-blocker, providers are urged to consider withholding the β-blocker or, if that is deemed impractical, to proceed cautiously with desensitization, with glucagon as well as epinephrine kept readily available at the bedside. Strong contraindications to antibiotic desensitization are the refusal of a patient to give written informed consent, the existence of a highly effective alternative antibiotic, and the inavailability of an intensive-care bed or high-level nursing care. Each of the protocols also outlines orders for the management of adverse events, should they occur. If there is any change in the patient’s clinical condition, vital signs, or physical examination results, the nurse must stop the infusion, notify the responsible physician(s), and administer rescue medications according to the severity of the reaction, as defined on the order set and protocol (Figure 1). For mild reactions, supplemental oxygen, diphenhydramine, albuterol, and epinephrine should be administered (Table 1). For reactions ranging from persistent-mild to severe, dexamethasone and an injectable histamine H2-receptor antagonist, such as famotidine, are given in addition to the medications listed for mild reactions. With a physician present at the bedside, further management medications must be ordered to control the adverse reactions. Specific recommendations for managing laryngospasm and stridor, including the administration of inhaled racemic epinephrine or (for patients receiving β-blockers) glucagon, are also delineated. Table 1. Management of Adverse Reactions to Desensitizationa Intervention Severity of Adverse Reaction Mild Moderate Severe Stop infusion +b + + Call house officer, attending physician(s), and on-call allergy and immunology fellow + + + Epinephrine p.r.n. for systemic effects +/−c + + Supplemental oxygen p.r.n. for dyspnea +/− +/− +/− Diphenhydramine p.r.n. for itching, urticaria +/− +/− +/− Nebulized albuterol p.r.n. for dyspnea, wheezing +/− +/− +/− Dexamethasone NA + + Famotidine NA + + Intervention Severity of Adverse Reaction Mild Moderate Severe Stop infusion +b + + Call house officer, attending physician(s), and on-call allergy and immunology fellow + + + Epinephrine p.r.n. for systemic effects +/−c + + Supplemental oxygen p.r.n. for dyspnea +/− +/− +/− Diphenhydramine p.r.n. for itching, urticaria +/− +/− +/− Nebulized albuterol p.r.n. for dyspnea, wheezing +/− +/− +/− Dexamethasone NA + + Famotidine NA + + a NA = not applicable. b Mandatory. c Must be ordered for use as needed and administered for specific adverse reaction as described by p.r.n. indication. Open in new tab Table 1. Management of Adverse Reactions to Desensitizationa Intervention Severity of Adverse Reaction Mild Moderate Severe Stop infusion +b + + Call house officer, attending physician(s), and on-call allergy and immunology fellow + + + Epinephrine p.r.n. for systemic effects +/−c + + Supplemental oxygen p.r.n. for dyspnea +/− +/− +/− Diphenhydramine p.r.n. for itching, urticaria +/− +/− +/− Nebulized albuterol p.r.n. for dyspnea, wheezing +/− +/− +/− Dexamethasone NA + + Famotidine NA + + Intervention Severity of Adverse Reaction Mild Moderate Severe Stop infusion +b + + Call house officer, attending physician(s), and on-call allergy and immunology fellow + + + Epinephrine p.r.n. for systemic effects +/−c + + Supplemental oxygen p.r.n. for dyspnea +/− +/− +/− Diphenhydramine p.r.n. for itching, urticaria +/− +/− +/− Nebulized albuterol p.r.n. for dyspnea, wheezing +/− +/− +/− Dexamethasone NA + + Famotidine NA + + a NA = not applicable. b Mandatory. c Must be ordered for use as needed and administered for specific adverse reaction as described by p.r.n. indication. Open in new tab Once the adverse reaction has resolved, the physician can determine how to proceed with the remainder of the desensitization. In the event of mild reactions, the protocol recommends continuing desensitization, but the infusion times should be extended. For patients with moderate reactions, the desensitization can be resumed at the last tolerated dose but with extended infusion times; for persistent-moderate and severe reactions, a consultation with an AIP is strongly suggested, as the decision to continue with desensitization depends on the severity of the reaction and the patient’s overall condition. Once desensitization is complete and the patient has received the first therapeutic dose, the patient must remain in the ICU for a minimum of two hours for additional monitoring for any delayed reaction. Although drug-specific standardized desensitizations do not reduce administration time, nursing staff greatly benefit from the development of a protocol. The protocol describes the desensitization process in detail, so regardless of how infrequently a nurse may administer desensitization medications, he or she can refer to the protocol for instruction; this enhances confidence and consistency, as well as patient safety. Although nine antibiotic regimens have been standardized, it is important to note that practice recommendations on desensitization have been updated within the past few years, and not all medications are appropriate candidates for standardization.5,10 The experiences of AIPs at our institution have demonstrated the difficulty of standardizing procedures for vancomycin and sulfamethozaxole–trimethoprim desensitization because of patient-specific needs and the difficulty of defining a final therapeutic dose based on patient weight. The template used for standardizing desensitizations in this process will be used for future agents that are deemed appropriate candidates for standardization. As UCH moves forward to CPOE with a campuswide integrated electronic medical record system, the standardized order sets already developed are being incorporated into these systems. Outcome measurements for ICU length of stay, protocol compliance, and patient tolerability are currently being analyzed. Conclusion Standardized antimicrobial desensitization protocols helped to optimize patient care and antimicrobial stewardship while enabling more efficient use of pharmacy and AIP resources and fostering enhanced pharmacist–physician collaboration. References 1 Grammer LC Greenberger PA . Drug allergy and protocols for management of drug allergies. 3rd ed. Providence, RI : OceanSide ; 2003 : 1 – 52 . COPAC 2 Gruchalla RS Pirmohamed M . Antibiotic allergy . N Engl J Med . 2006 ; 354 : 601 – 9 . Google Scholar Crossref Search ADS PubMed WorldCat 3 Leoung GS Stanford JF Giordano MF et al. Trimethoprim–sulfamethoxazole (TMP–SMZ) dose escalation versus direct rechallenge for Pneumocystis carinii pneumonia prophylaxis in human immunodeficiency virus-infected patients with previous adverse reaction to TMP–SMZ . JID . 2001 ; 184 : 992 – 7 . Google Scholar Crossref Search ADS PubMed WorldCat 4 Borish L Tamir R Rosenwasser LJ . Intravenous desensitization to beta-lactam antibiotics . J Allergy Clin Immunol . 1987 ; 80 : 314 – 9 . Google Scholar Crossref Search ADS PubMed WorldCat 5 Joint Task Force on Practice Parameters American Academy of Allergy, Asthma and Immunology American College of Allergy, Asthma and Immunology Joint Council of Allergy Asthma and Immunology ; Drug allergy: an updated practice parameter . Ann Allergy, Asthma Immunol . 2010 ; 105 : 259 – 73 . Crossref Search ADS WorldCat 6 Dellit TH Owens RC Jr McGowan JE Jr et al. . Infectious Diseases Society of America and the Society for Healthcare Epidemiology of America guidelines for developing an institutional program to enhance antimicrobial stewardship . Clin Infect Dis . 2007 ; 44 : 159 – 77 . Google Scholar Crossref Search ADS PubMed WorldCat 7 Pichler WJ . Delayed drug hypersensitivity reactions . Ann Intern Med . 2003 ; 139 : 683 – 93 . Google Scholar Crossref Search ADS PubMed WorldCat 8 Pichichero M . A review of evidence supporting the American Academy of Pediatrics recommendation for prescribing cephalosporin antibiotics for penicillin-allergic patients . Pediatrics . 2005 ; 115 : 1048 – 57 . Google Scholar Crossref Search ADS PubMed WorldCat 9 Lieberman P Kemp SF Oppenheimer J et al. The diagnosis and management of anaphylaxis: an updated practice parameter . J Allergy Clin Immunol . 2005 ; 115 : S483 – 523 . Google Scholar Crossref Search ADS PubMed WorldCat 10 Mirakian R Ewan PW Durham SR et al. BSACI guidelines for the management of drug allergy . Clin Exp Allergy . 2009 ; 39 : 43 – 61 . Google Scholar Crossref Search ADS PubMed WorldCat Author notes The authors have declared no potential conflicts of interest. Copyright © 2013 by the American Society of Health-System Pharmacists, Inc. All rights reserved.
TI - Implementing standardized intravenous antibiotic desensitizations among hospital inpatients
JO - American Journal of Health-System Pharmacy
DO - 10.2146/ajhp110718
DA - 2013-03-15
UR - https://www.deepdyve.com/lp/oxford-university-press/implementing-standardized-intravenous-antibiotic-desensitizations-aGqXFtgOpi
SP - 540
VL - 70
IS - 6
DP - DeepDyve
ER -