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- Title
Association Between Removal of a Warning Against Cephalosporin Use in Patients With Penicillin Allergy and Antibiotic Prescribing.
- Authors
Macy, Eric; McCormick, Thomas A.; Adams, John L.; Crawford, William W.; Nguyen, Myngoc T.; Hoang, Liem; Eng, Victoria; Davis, Anna C.; McGlynn, Elizabeth A.
- Abstract
This cohort study assesses whether removal of a warning against use of cephalosporins in the electronic health record (EHR) of patients with penicillin allergy was associated with changes in the dispensing or administration of cephalosporins. Key Points: Question: Is removal of a warning to avoid cephalosporin use in patients with penicillin allergies associated with an increase in cephalosporin dispensing or administration? Findings: In this cohort study of 4 398 792 patients who had received antibiotic treatment, after an alert in the electronic health record system to avoid prescribing of cephalosporins to patients with a penicillin allergy was removed at 1 of 2 health system sites, cephalosporin dispensing or administration increased significantly among patients with a penicillin allergy at that site compared with patients without a penicillin allergy at the same site and patients at the comparison site that retained the warning. Meaning: In this study, removal of a warning in the electronic health record to avoid cephalosporin use in patients with penicillin allergies was associated with increased dispensing and administration of cephalosporin. Importance: Electronic health records (EHRs) often include default alerts that can influence physician selection of antibiotics, which in turn may be associated with a suboptimal choice of agents and increased antibiotic resistance. Objective: To examine whether removal of a default alert in the EHR to avoid cephalosporin use in patients with penicillin allergies is associated with changes in cephalosporin dispensing or administration in these patients. Design, Setting, and Participants: This retrospective cohort study of a natural experiment included data on patients who had received antibiotic treatment in the hospital or outpatient setting in 2 regions of a large, integrated health system in California from January 1, 2017, to December 31, 2018. Of 4 398 792 patients, 4 206 480 met the eligibility criteria: enrollment in the health system during antibiotic use, availability of complete demographic data, and use of antibiotics outside of the washout period. Interventions or Exposures: Oral or parenteral antibiotics dispensed or administered after removal of an EHR alert to avoid cephalosporin use in patients with a recorded penicillin allergy. Main Outcomes and Measures: Probability that an antibiotic course was a cephalosporin. A multinomial logistic regression model was used to examine the change in rates of cephalosporin use before and after an EHR penicillin allergy alert was removed in 1 of the study regions. Temporal changes in use rates were controlled for by comparing changes in cephalosporin use among patients with or without a penicillin allergy at the site that removed the warning and among patients at a comparison site that retained the warning. Regression models were used to examine adverse events. Results: Of the 4 206 480 patients who met all inclusion criteria, 2 465 849 (58.6%) were women; the mean (SD) age was 40.5 (23.2) years. A total of 10 652 014 antibiotic courses were administered or dispensed, divided approximately evenly between the period before and after removal of the warning. Before removal of an alert in the electronic health record system to avoid prescribing of cephalosporins to patients with a penicillin allergy at 1 of the 2 sites, 58 228 courses of cephalosporins (accounting for 17.9% of all antibiotic use at the site) were used among patients with a penicillin allergy; after removal of the alert, administration or dispensing of cephalosporins increased by 47% compared with cephalosporin administration or dispensing among patients without a penicillin allergy at the same site and patients at the comparison site that retained the warning (ratio of ratios of odds ratios [RROR], 1.47; 95% CI, 1.38-1.56). No significant differences in anaphylaxis (9 total cases), new allergies (RROR, 1.02; 95% CI, 0.93-1.12), or treatment failures (RROR, 1.02; 95% CI, 0.99-1.05) were found at the course level. No significant differences were found in all-cause mortality (ratio of ratios of rate ratios [RRRR], 1.03; 95% CI, 0.94-1.13), hospital days (RRRR, 1.04; 95% CI, 0.99-1.10), and new infections (Clostridioides difficile: RRRR, 1.02; 95% CI, 0.84-1.22; methicillin-resistant Staphylococcus aureus: RRRR, 0.87; 95% CI, 0.75-1.00; and vancomycin-resistant Enterococcus: RRRR, 0.82; 95% CI, 0.55-1.22) at the patient level. Conclusions and Relevance: In this cohort study, removal of a warning in the electronic health record to avoid cephalosporin use in patients with penicillin allergies was associated with increased administration and dispensing of cephalosporin. This simple and rapidly implementable system-level intervention may be useful for improvement in antibiotic stewardship.
- Subjects
CALIFORNIA; CONFIDENCE intervals; RETROSPECTIVE studies; REGRESSION analysis; CEPHALOSPORINS; PENICILLIN; DRUG prescribing; ELIGIBILITY (Social aspects); DESCRIPTIVE statistics; ELECTRONIC health records; DRUG allergy; PHYSICIAN practice patterns; ODDS ratio; ANTIBIOTICS; LONGITUDINAL method
- Publication
JAMA Network Open, 2021, Vol 4, Issue 4, pe218367
- ISSN
2574-3805
- Publication type
Article
- DOI
10.1001/jamanetworkopen.2021.8367