TY - JOUR
AU - Bland, Christopher, M.
AB - Abstract Purpose An initiative to determine the effects of penicillin skin testing (PST) from an antimicrobial stewardship perspective is described. Summary Penicillin allergy is one of the most frequently reported allergies; however, only about 10% of self-reports of penicillin allergy are accurate. Incorrect penicillin allergies are therefore a significant barrier to antimicrobial stewardship, with important clinical and economic implications, including increased antimicrobial resistance, an increased overall cost of care, increased length of stay, and, ultimately, increased mortality. As part of its antimicrobial stewardship program, a community health system launched a PST initiative in order to optimize therapy, reduce adverse events acquisition costs, and minimize development of antibiotic resistance. The PST program involves the use of a standardized protocol for the assessment of hypersensitivity to penicillin in patients with suspected penicillin allergy. Among 36 patients who completed the PST protocol during an eight-month period, all had a negative result; in 27 of those patients, a conversion of antimicrobial therapy to a penicillin or cephalosporin was implemented as a direct result of PST. Conclusion In patients with a self-reported penicillin allergy, PST led to a reduction in the use of carbapenems, aztreonam, vancomycin, and other broad-spectrum agents within a health system. A decrease in drug costs was documented in a sample of patients switched to a penicillin or a cephalosporin after PST. allergy, penicillin, pharmacist, skin test, stewardship Penicillin allergy is one of the most frequently reported allergies; however, as many as 90% of self-reports of penicillin allergies are inaccurate.1 Incorrect penicillin allergies therefore constitute a major barrier to antimicrobial stewardship, with significant clinical and economic implications, including increased antimicrobial resistance, overall care costs, and length of stay and, ultimately, increased mortality.2 Penicillins and cephalosporins are the drugs of choice for many infectious diseases indications, including surgical prophylaxis, treatment of methicillin-susceptible Staphylococcus aureus infections, and treatment of invasive streptococcal infections and sexually transmitted infections such as syphilis. In March 2015 the White House released the report National Action Plan for Combating Antibiotic-resistant Bacteria, which stipulates that by 2020, antimicrobial stewardship programs (ASPs) are to be established in all acute care hospitals, with improved antimicrobial stewardship implemented across all healthcare settings.3 Penicillin skin testing (PST) offers a unique opportunity in antimicrobial stewardship to not only benefit the patient during an acute episode of infection but also provide downstream stewardship effects by facilitating the prescribing of β-lactam agents and avoidance of other, costlier agents with potentially more serious adverse effects, including treatment-related Clostridium difficile infection. PST therefore can promote several core elements of antimicrobial stewardship, including de-escalation of therapy and parenteral-to-oral conversion when patients are demonstrated to be non–penicillin allergic.4 Identifying true drug allergies is a major obstacle for healthcare providers because of several factors. First of all, recognizing the difference between an adverse drug reaction and a true allergy can be confusing, especially for a patient. Another challenge in identifying drug allergies is difficulty assigning blame. Oftentimes patients receive multiple drugs, especially if they are inpatients at a hospital; if a patient develops hives after initiation of therapy, antimicrobials are often blamed. Also, in many cases patients are not re-challenged with suspected causative medications, and a suspected allergy is linked to the patient indefinitely. The question for many providers becomes this: How do we use penicillin and related agents when a subjective drug allergy is reported by the patient? PST is the most useful method of detecting immunoglobulin E (IgE)–mediated penicillin allergies due to its high sensitivity. It is the only standardized method of drug allergy testing currently available in the United States. The negative predictive value of skin testing has been shown to be approximately 99%. Specific IgE in vitro assays with high specificity are available, but they have been demonstrated to have much lower sensitivity than skin testing; this means that a negative IgE assay result cannot definitively rule out penicillin allergy and, therefore, that skin testing is preferred.1,5 Benzylpenicilloyl polylysine is a PST antigen indicated for the assessment of hypersensitivity to penicillin in patients with a history of penicillin allergy. The antigen reacts with benzylpenicilloyl IgE antibodies, causing the release of chemical mediators that result in the development of wheal and flare reactions at the injection site. Prior to 2004, benzylpenicilloyl polylysine had been in use for approximately 30 years. The previous supplier, however, was unable to provide an adequate manufacturing facility for the product, resulting in its removal from the market in 2004. As benzylpenicilloyl polylysine was the only available reagent for PST, its removal from the market limited treatment options in patients with a reported penicillin allergy. The formation of AllerQuest LLC, and that company’s subsequent partnership with ALK-Abelló, Inc., led to benzylpenicilloyl polylysine’s return to the market on September 18, 2009.6,7 Key Points Approximately 10% of patients report hypersensitivity to penicillin, but up to 90% of patients do not have true penicillin allergy. A reagent-based penicillin skin testing method (the only standardized drug allergy test in the United States) has a negative predictive value of approximately 99%. Testing involves a two-step process (with an optional third step) that takes approximately 45–60 minutes. Penicillin skin testing can result in reduced use of carbapenems, aztreonam, vancomycin, and other broad-spectrum agents. The skin test is administered in two steps, with an optional third step. The first step involves puncture testing, in which small drops of benzylpenicilloyl polylysine injection (the major determinant), prediluted penicillin G potassium injection (a minor determinant), histamine phosphate injection (a positive control), and 0.9% sodium chloride injection (a negative control) are placed on the inner forearm; a sterile puncture stick is then used to puncture the epidermis in the center of each drop. The patient should be observed for a positive reaction for a period of 15–20 minutes. The histamine control must elicit a reaction in order for a positive test result to be valid. A positive reaction is defined as the development of a pale wheal around the site of injection that is 3 mm larger than the wheal at the negative control site (if any). If a positive reaction to either benzylpenicilloyl polylysine or penicillin G is observed, the solution should be removed from the skin immediately, and the patient is considered to have a true IgE-mediated allergy. If the patient experiences no reaction or the diameter of the wheal is not 3 mm larger than that seen with the negative control, the second portion of the test may be administered.7,8 The second step in the test consists of an intradermal test, in which a series of five intradermal injections are given in the outer portion of the upper arm, just below the deltoid. Two duplicate blebs are created using benzylpenicilloyl polylysine and penicillin G, and an additional bleb is created using 0.9% sodium chloride injection to serve as a control. The margins of the initial blebs, which are typically around 3 mm, are marked on the skin. After a period of 15–20 minutes, the test site is evaluated for a positive or negative reaction. A positive reaction is defined as an expansion of the original bleb by more than 2 mm or a bleb that is more than 2 mm larger than the control. A negative response is defined as no increase in the size of the bleb or no bleb larger than that observed with the control. If the response is ambiguous, the test should be repeated.7 If the prescriber chooses, an oral challenge with a penicillin therapy such as 250 mg of oral amoxicillin may then be carried out. Incorporating skin testing into antimicrobial stewardship St. Joseph’s/Candler Health System is a 714-bed community-based regional referral health system in Savannah, Georgia. The health system consists of two hospitals, St. Joseph’s Hospital and Candler Hospital. An ASP was instituted at St. Joseph’s/Candler Health System in keeping with Infectious Diseases Society of America (IDSA) guidelines regarding antimicrobial stewardship. The primary goal of the program is to improve clinical outcomes while limiting adverse events and antimicrobial resistance. In accordance with a recommendation from the ASP committee and after approval by the pharmacy and therapeutics committee, PST was added to the health system’s formulary. The stewardship pharmacist evaluates all patients prescribed PST for exclusions for use ( Appendix A) and any medications that would interfere with conducting the test (e.g., antihistamines). The product is then profiled and prepared by the stewardship pharmacist, who assists the nurse in all aspects of the test. The ASP committee developed a protocol ( Appendix B), adopted from the manufacturer-provided protocol and modified to fit the institution’s needs, to instruct nursing staff in PST administration. The protocol includes specific documentation of the results and interpretation of the test. Having the stewardship pharmacist present allows for a second evaluation of the patient and staff consistency in the PST process. The stewardship pharmacist is responsible for updating information on patient allergies and contacting the prescribing physician for changes in antimicrobial therapy. Patients are counseled on the test results, especially in the event of a negative test indicating that they are no longer allergic to penicillin, in which case they are asked to inform all of their healthcare providers. Prescribing of a penicillin antimicrobial after a positive PST result is currently restricted to an order directly from an infectious diseases physician and physician orders based on a recommendation from the stewardship pharmacist during day-shift hours, including weekends. Physicians, pharmacists, nursing personnel, and other interested parties, such as infection–control personnel and students, should be trained in the PST process. If the decision is made to adopt PST, representatives from the reagent manufacturer are available to come onsite to provide comprehensive training. Once a person is trained and credentialed to perform the test, he or she is permitted to train other personnel in the health system. A yearly competency is administered electronically so that trained individuals can maintain the PST credential. Identifying who will perform the test is important. If an allergist is on staff at a particular institution and is willing to participate in PST, he or she is an ideal candidate; some facilities have physicians in residency training or an infectious diseases fellow serve in this role (pharmacist involvement may be an option, depending on state law). Our institution is a community-based health system without allergists, medical residents, or fellows, so it was decided to implement a nursing staff–driven process with clinical pharmacist involvement. Early experience with the program Data were collected on all adult inpatients at St. Joseph’s/Candler Health System who received PST over an open enrollment period (July 2014–March 2015). Patients were identified from a computer-generated list and included in the analysis if they completed all required steps of the PST protocol. Patients were excluded from the analysis if they met the criteria for exclusions defined by the institution ( Appendix A). Forty-six patients who had received PST during the open enrollment period were identified. Ten patients were excluded due to failure to complete all required steps of the PST protocol. None of the 10 excluded patients had a positive reaction to the histamine control during the puncture phase of testing, so they could not proceed to the intradermal phase. The most common indication for antimicrobials was skin and soft tissue infection. Other common indications included urinary tract infections, osteomyelitis, and pneumonia. Among the 36 patients included in the analysis, the most common type of self-reported reaction to a β-lactam antimicrobial before PST was “unknown reaction” (n = 20, 55% of patients), with rash (n = 8, 24%) and hives (n = 4, 10%) also frequently reported. All 36 patients included in the analysis had a negative reaction to PST. For 27 patients, a switch in antimicrobial therapy to a penicillin or cephalosporin was implemented as a direct result of PST. The most common change in therapy was conversion from a carbapenem (with or without vancomycin) to a penicillin or a cephalosporin, which occurred in 12 patients. Other changes in therapy included conversions from vancomycin, aztreonam, or an aminoglycoside to a penicillin or a cephalosporin. Three patients who were not receiving an antimicrobial prior to testing were initiated on a penicillin or a cephalosporin after the test. Of the patients with a negative reaction to PST who subsequently received a β-lactam antimicrobial in the hospital, none had a documented reaction to the β-lactam. As part of postprocedural follow-up, allergy information was updated in the electronic medical record for all patients tested; test results were conveyed to prescribing physicians, with subsequent order changes implemented as necessary. Twenty-four patients were included in a cost analysis of testing; 9 patients whose antimicrobial therapy was not changed due to results of PST and 3 patients with no active antimicrobial orders at the time of testing were excluded. The average antimicrobial acquisition cost savings per patient was approximately $314.75, yielding an expected total cost savings of approximately $7554.08. Cost savings were calculated as the difference in the acquisition costs of initially prescribed and post-PST therapy multiplied by the total number of days of antimicrobial therapy. Discussion A 2009 publication noted that few novel antimicrobials were in development in the United States, partly due to pharmaceutical industry withdrawal from acute infectious diseases–focused research and development.9 Therefore, practitioners are often limited in their options for treating many infections, including those caused by multidrug-resistant (MDR) organisms, leading to increased morbidity and mortality. Self-reported penicillin allergy is another major factor that limits appropriate antimicrobial prescribing for both non-MDR organisms (such as group A Streptococcus species) and MDR organisms such as Pseudomonas and Acinetobacter species. Patient reports of penicillin allergies are often found to be inaccurate with PST. Many facilities do not have continual support from allergists, who historically have performed PST. Infectious diseases physicians are often not consulted on many of the cases in which PST could be beneficial. Commercially available PST allows pharmacists involved in ASPs a unique opportunity to facilitate PST in a number of different facilities, including community hospitals. Pharmacists could also potentially work through interdisciplinary care with allergists, nursing personnel, and infectious diseases physicians to develop a comprehensive PST service to enhance antimicrobial stewardship in both inpatient and outpatient care areas. Recently published joint guidelines from IDSA and the Society for Healthcare Epidemiology of America recommend allergy assessments and PST in appropriately selected patients; however, published data on PST as a primary ASP initiative are limited.10 PST implementation, coordinated by a stewardship pharmacist and infectious diseases physicians, led to cost savings for the institution. The estimate of cost savings of approximately $300 per patient was conservative, as that figure only accounted for drug acquisition cost. Further cost savings potentially could be manifested in optimization of clinical outcomes (e.g., use of nafcillin against methicillin-susceptible Staphylococcus aureus instead of vancomycin), prevention of adverse effects of alternative agents (e.g., C. difficile infection with use of broad-spectrum antimicrobials), and decreased length of stay (the option of using penicillin agents can facilitate a switch to an oral antimicrobial to allow for discharge). More importantly, PST can result in not only a significant benefit during an acute episode of care but subsequent longitudinal benefits for patients who might require further antimicrobial therapy over the course of their lifetime. A good example is PST-enabled use of penicillins for dental extraction procedures; patients labeled as penicillin allergic typically receive clindamycin, whose use is associated with a higher risk of C. difficile infection. Future studies should seek to ascertain the long-term clinical and economic benefits that can result from PST. In order for PST to be most beneficial, documentation of PST results must be shared among all healthcare providers, such as dentists (who prescribe a significant percentage of antimicrobials). If PST results are not communicated among all providers, this could result in continued inappropriate labeling of a patient as “penicillin allergic.” St. Joseph’s/Candler Health System works together with other hospitals in the Savannah area to establish citywide stewardship initiatives in order to maximize program benefits across the region. The system is currently evaluating the feasibility of PST in long-term care facilities, where patients often receive long-duration antimicrobial therapy for which a β-lactam agent would be ideal. Future studies should also seek to evaluate the potential benefits of PST in long-term care populations as well as in outpatients likely to receive antimicrobials for surgical prophylaxis. One challenge of PST implementation is the time commitment required to train members of the healthcare team and administration of the test. From the moment a patient is identified as a candidate for PST through completion of the test (and any follow-up to physicians and updating of the allergy history), a pharmacist can spend as much as 1.5 hours involved in the process (that time is not all spent at the bedside, and other tasks can be performed concurrently). Nurses can spend close to an hour administering the test (although not all with direct care responsibility). These time demands may necessitate triage to focus testing efforts on patients who stand to derive the most benefit from PST; at St. Joseph’s/Candler Health System, priority is given to patients receiving broad-spectrum antimicrobials or alternative therapies for whom a β-lactam would be the therapy of choice. A notable limitation of our analysis was the exclusion of patients due to a nonreactive histamine puncture test. A negative reaction led to the process being stopped and the test not completed. This could be due to several reasons, with administration technique and recent antihistamine use the most likely contributors. Conclusion In patients with a self-reported penicillin allergy, PST led to a reduction in the use of carbapenems, aztreonam, vancomycin, and other broad-spectrum agents within a health system. A decrease in drug acquisition costs was documented in a sample of patients switched to a penicillin or a cephalosporin after PST. Disclosures Dr. Jones and Dr. Bland have received honoraria and grant funding from ALK-Abelló, Inc. The authors have declared no other potential conflicts of interest. Appendix A St. Joseph’s/Candler Health System criteria for exclusion from penicillin skin testing History of anaphylaxis during use of a β-lactam agent within the last 10 years Anaphylaxis due to any cause within the previous four weeks History of a skin condition that could interfere with accurate reading of test results Diagnosis of human immunodeficiency virus infection and a CD4+ T-lymphocyte count of <500 cells/mm3 or history of opportunistic infection Cystic fibrosis Neutropenia (absolute neutrophil count of <1000 cells/mm3) Appendix B St. Joseph’s/Candler Health System penicillin skin testing protocol, as adapted from protocol provided by manufacturer of benzylpenicilloyl polylysine (BPP) Pharmacy Code: Original Date: Reviewed: Revised: Order Name:   Penicillin Skin Testing Diagnosis: Allergies: Height Weight Pharmacy Code: Original Date: Reviewed: Revised: Order Name:   Penicillin Skin Testing Diagnosis: Allergies: Height Weight Open in new tab Pharmacy Code: Original Date: Reviewed: Revised: Order Name:   Penicillin Skin Testing Diagnosis: Allergies: Height Weight Pharmacy Code: Original Date: Reviewed: Revised: Order Name:   Penicillin Skin Testing Diagnosis: Allergies: Height Weight Open in new tab Must be ordered by an infectious diseases (ID) physician or antimicrobial stewardship program (ASP) team physician before being administered. Preprocedure: Penicillin skin testing should only be performed by nursing staff who have received the proper training to administer the test. Fax protocol to pharmacy. Follow hypersensitivity reaction protocol below if patient experiences an adverse reaction to the test. Testing is only available between the hours of 0800 and 1600. Procedure: Step 1) Prick Test This will be performed first on the patient, before proceeding to intradermal testing. Clean the volar surface of either forearm with an alcohol swab. Using an ink pen, draw 3 vertical lines approximately 1 inch apart on the designated testing site of the arm. Draw up 0.1 mL of the 4 solutions (BPP, diluted penicillin G, histamine positive control, and saline negative control) in 4 separate allergy syringes. Apply a small drop of each solution to the separate pre-marked sites on the testing arm. The histamine test site should be the most distal site from the elbow, followed up the arm by saline, BPP, and penicillin G. Puncture the epidermis using a twisting motion with a sterile 22–28 gauge needle or puncture stick at each drop site. Do not draw blood. Very little pressure is required. Read the test in 15–20 minutes: (document test results below) Test is negative: change in diameter of wheal is less than 3 mm than that observed with the negative control. Proceed to intradermal test. Test is positive: change in diameter of wheal is greater than 3 mm than that observed with the negative control. As soon as a positive response is observed, the solution should be wiped off the skin. Do not proceed to intradermal test. The positive control (histamine skin test) should be positive to ensure the results are not falsely negative. The negative control (saline skin test) should be negative. If a wheal >2–3 mm develops after 20 minutes, repeat prick skin test. Upon re-testing, if control still creates a wheal >2–3 mm after 20 minutes, discontinue test and notify the ID Physician and/or the ID Stewardship Pharmacist. Step 2) Intradermal Test Only conduct this test if patient produced a negative result with the prick test in step 1. Select 5 sites on the volar surface on the forearm. These sites should be on the opposite arm from the prick test if possible. Using a 26–30 gauge, short bevel needle, intradermally inject 0.02 mL of BPP solution twice (separate at least 2 cm apart). Mark the margins of the initial blebs with an ink pen. Using separate needles and syringes, intradermally inject diluted penicillin G (0.02 mL = 200 units of penicillin) twice (separate at least 2 cm apart) and 0.02 mL of saline (separate at least 5 cm apart from other sites). Read in 20 minutes: (document test results below) Test is negative: there is no increase in the original bleb and no greater reaction than the negative control site. Test is positive: bleb or wheal increases >2 mm from its original size or is >2 mm larger than the negative control. Patient is NOT to receive penicillin. Step 3) (Optional) Oral Penicillin Challenge If deemed necessary by ordering physician Oral penicillin (e.g., amoxicillin 250 mg) challenge or graded challenge of target drug in a monitored setting for 30–45 minutes. Post-Procedure Follow-up: Monitor patient’s vital signs every 15 minutes for the first hour after the initial dose of penicillin is received. Monitor for sign of possible adverse drug reactions for the duration of penicillin treatment. Notify ordering physician of test results. Report any signs of adverse drug reactions to the ordering ID physician or ASP representative. Scan results to pharmacy for allergy information to be updated. Treatment of Acute Reactions For all reactions, immediately stop medication and monitor vital signs every 15–30 minutes for duration of reaction. Immediately notify the ordering physician. Notify charge nurse. Select treatment regimen based on severity of reaction: mild, moderate, and severe reactions. Treat the most severe reaction first. Mild reactions (identified by nausea, vomiting, altered taste, sweats, cough, itching, rash or hives, warmth, pallor, flushing, dizziness, chills, shaking, swelling of eyes or face, hypotension): Diphenhydramine 25 mg slow intravenous push over 1–2 minutes × 1 dose. If symptoms persist for 15 minutes and physician has not called back, may give famotidine 20 mg slow intravenous push over 1–2 minutes × 1 dose. Moderate reactions (identified by more severe, systemic signs or symptoms including tachycardia/bradycardia, hypotension, bronchospasm, wheezing, dyspnea, pronounced cutaneous reaction): Diphenhydramine 25 mg slow intravenous push over 1–2 minutes × 1 dose. If symptoms persist for 5 minutes and physician has not called back, may give famotidine 20 mg slow intravenous push over 1–2 minutes × 1 dose. Epinephrine (1:1000) solution 0.5 mg (0.5 mL) subcutaneously × 1 dose. May repeat every 20 minutes as needed. Oxygen (O2) as needed for bronchospasms. Titrate to O2 saturation greater than 93%. Methylprednisolone 125 mg slow intravenous push over 1–2 minutes × 1 dose. Severe reaction (identified by life-threatening, more severe signs or symptoms, including laryngeal edema, profound hypotension, unresponsiveness, convulsions, clinically manifest arrhythmias, cardiopulmonary arrest): If patient is located in a non-unit bed, call a CODE CAT and proceed with steps below. Diphenhydramine 25 mg slow intravenous push over 1–2 minutes × 1 dose. If symptoms persist, may give famotidine 20 mg slow intravenous push over 1–2 minutes × 1 dose. Epinephrine (1:1000) solution 0.1 mg (0.1 mL) diluted in 10 mL of normal saline given intravenously over 5 minutes (1–2 mL per minute). If bronchospasm unresolved after epinephrine, administer albuterol inhaler two puffs × 1 dose. Oxygen (O2) as needed for bronchospasms. Titrate to O2 saturation greater than 93%. Methylprednisolone 125 mg slow intravenous push over 1–2 minutes × 1 dose. If still no response and no return call from physician initial contact, initiate emergency interventions as appropriate. Nurse Performing Test: _______________________________________________ Test Date Product Prick Width (mm) Intradermal #1 Width (mm) Intradermal #2 Width (mm) Results (Pos/Neg/Ambiguous) BPP (undiluted) Penicillin G (10,000 U/mL) Diluent Control Histamine (1.0 mg/mL) Test Date Product Prick Width (mm) Intradermal #1 Width (mm) Intradermal #2 Width (mm) Results (Pos/Neg/Ambiguous) BPP (undiluted) Penicillin G (10,000 U/mL) Diluent Control Histamine (1.0 mg/mL) Open in new tab Test Date Product Prick Width (mm) Intradermal #1 Width (mm) Intradermal #2 Width (mm) Results (Pos/Neg/Ambiguous) BPP (undiluted) Penicillin G (10,000 U/mL) Diluent Control Histamine (1.0 mg/mL) Test Date Product Prick Width (mm) Intradermal #1 Width (mm) Intradermal #2 Width (mm) Results (Pos/Neg/Ambiguous) BPP (undiluted) Penicillin G (10,000 U/mL) Diluent Control Histamine (1.0 mg/mL) Open in new tab Interpretation NEGATIVE for penicillin allergy POSITIVE for penicillin allergy Physician Signature:_________________________________ Date:________________ Time:___________ References 1 Solensky R Khan DA Bernstein IL . Drug allergy: an updated practice parameter . Ann Allergy Asthma Immunol . 2010 ; 105 : 259 – 73 . Google Scholar Crossref Search ADS PubMed WorldCat 2 Unger NR Gauthier TP Cheung LW . Penicillin skin testing: potential implications for antimicrobial stewardship . Pharmacotherapy . 2013 ; 33 : 856 – 67 . Google Scholar Crossref Search ADS PubMed WorldCat 3 The White House . National action plan for combating antibiotic-resistant bacteria ( March 2015 ). www.whitehouse.gov/sites/default/files/docs/national_action_plan_for_combating_antibiotic-resistant_bacteria.pdf (accessed 2016 Mar 9). 4 Dellit TH Owens RC McGowan JE Jr . 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 5 Executive summary of disease management of drug hypersensitivity: a practice parameter . Joint Task Force on Practice Parameters, the American Academy of Allergy, Asthma and Immunology, and the Joint Council of Allergy, Asthma and Immunology . Ann Allergy Asthma Immunol . 1999 ; 83 : 665 – 700 . Crossref Search ADS PubMed WorldCat 6 AllerQuest LLC . Pre-Pen update . www.allerquest.com/availability.html (accessed 2014 Aug 19). 7 Pre-Pen (benzylpenicilloyl polylysine) package insert . Plainville, CT : Hospira, Inc., and AllerQuest LLC ; 2009 . WorldCat COPAC 8 Rimawi RH Cook PP Gooch M . The impact of penicillin skin testing on clinical practice and antimicrobial stewardship . J Hosp Med . 2013 ; 8 : 341 – 5 . Google Scholar Crossref Search ADS PubMed WorldCat 9 Boucher HW Talbot GH Bradley JS . Bad bugs, no drugs: no ESKAPE! An update from the Infectious Diseases Society of America . Clin Infect Dis . 2009 ; 48 : 1 – 12 . Google Scholar Crossref Search ADS PubMed WorldCat 10 Barlam TF Cosgrove SE Abbo LM . Implementing an antibiotic stewardship program: guidelines by the Infectious Diseases Society of America and the Society for Healthcare Epidemiology of America . Clin Infect Dis . 2016 ; 62 : e51 – 77 . Google Scholar Crossref Search ADS PubMed WorldCat Copyright © 2017 by the American Society of Health-System Pharmacists, Inc. All rights reserved.
TI - Penicillin skin testing as an antimicrobial stewardship initiative
JO - American Journal of Health-System Pharmacy
DO - 10.2146/ajhp160233
DA - 2017-02-15
UR - https://www.deepdyve.com/lp/oxford-university-press/penicillin-skin-testing-as-an-antimicrobial-stewardship-initiative-sK4NzARDxm
SP - 232
VL - 74
IS - 4
DP - DeepDyve
ER -