Guideline for penicillin skin testing reduces use of penicillin alternatives

Source: icanPREVENT.com

By Robert Roos,
icanNEWS staff

icanNEWS –- The use of a practice guideline for penicillin skin testing increased the appropriate use of such testing and reduced the use of alternatives to penicillin, but it did not save money in a single course of treatment, according to a report published in the Jun 15 issue of Clinical Infectious Diseases.

However, the authors suggest that use of the guideline would pay off in the long run. "The knowledge that a patient does not have IgE [immunoglobulin E]-mediated allergy to penicillins should obviate the need for successive skin testing or use of alternative antibiotics during subsequent clinical encounters," state David Forrest and associates from St. Paul's Hospital, University of British Columbia, Vancouver.

The skin testing guideline was developed by an interdisciplinary team and was implemented at the hospital in May 1996. The investigators analyzed patient records to assess the appropriateness of skin testing and daily antibiotic costs during a 3.5-year period before introduction of the guideline and during 2 years after its introduction. They targeted patients who had a history of penicillin allergy reported at admission, had one of the diagnoses listed in the guideline, and had been treated with intravenous antibiotics for at least 7 days.

The authors found 64 patients from the pre-guideline period and 95 patients from the post-introduction period who fit the criteria. Before use of the guideline, penicillin skin tests were done on 11 of 64 patients (17%) during their hospitalization. After the guideline's adoption, the proportion increased to 61 of 95 eligible patients (64%) (95% confidence interval, 54% to 74%; P<.001).

Before the guideline's adoption, 10 of 11 patients had negative skin test results, and antibiotic treatment was changed to a penicillin for 7 of these 10 (70%). After the advent of the guideline, 58 of 61 tested patients had negative skin tests, and the antibiotic was switched for 54 of the 58 (93%). The average daily cost of antibiotics alone decreased from $37.24 before adoption of the guideline to $30.00 afterward. But when the costs of skin tests and vancomycin were included, the cost difference narrowed, with average daily costs of $39.84 before adoption of the guideline and $38.27 afterward. Neither difference was significant.

When only the costs of antibiotics were considered, the researchers estimated average potential savings of $80.07 per patient for those whose antibiotics were changed on the basis of a negative skin test. But when the costs of skin testing and vancomycin were included, use of the guideline resulted in an estimated average cost increase of $80.12 per patient, the report says. However, neither figure was significantly different from 0.

"Although introduction of this practice guideline for penicillin did not achieve financial savings during the hospitalization in which the guideline was introduced, we believe that its usefulness extends beyond this hospitalization," the authors say. Besides noting that appropriate skin testing can eliminate the need for further testing and alternative antibiotics at later clinical encounters, they comment, "The use of penicillins rather than vancomycin will likely decrease the incidence of infections caused by vancomycin-resistant strains of bacteria." They caution that the guideline applies only to IgE-mediated reactions to penicillins; a negative skin test does not preclude a delayed reaction, such as Stevens-Johnson syndrome.

Forrest DM, Schellenberg RR, Thien VS, et al. Introduction of a practice guideline for penicillin skin testing improves the appropriateness of antibiotic therapy. Clin Infect Dis 2001;32(12):1685-90 Abstract.

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