Cut It Out! Removing EHR Allergy Warnings to Improve Antimicrobial Stewardship

Authors:
Brian Wenger, PharmD
Nora Sharaya, PharmD, BCPS, BCACP, BC-ADM

Reviewers:
Katie E. Barber, PharmD
Frank Fanizza, PharmD, BCACP

Citation: Macy E, McCormick TA, Adams JL, et al. Association Between Removal of a Warning Against Cephalosporin Use in Patients With Penicillin Allergies and Antibiotic Prescribing. JAMA Network Open. 2021;4(4):e218367.

The Problem

WARNING: Patient has a penicillin allergy!  Do you want to continue with this cephalexin order?

This alert pops up in nearly every electronic health record in nearly every healthcare setting.  And providers address the warning in a variety of ways. Some ignore the alert.  Some ask the patient more questions about their penicillin allergy.  But all too often the patient is switched to a different antibiotic – one that is more costly, broader spectrum, and perhaps less effective.  The Centers for Disease Control and Prevention (CDC) estimates that although 10% of the US population report a penicillin allergy, less than one percent are truly allergic.¹ Although these warnings are commonplace, the evidence regarding the immunologic cross-reactivity between penicillins and cephalosporins is weak.^1,2 Unfortunately, when a B-lactam is indicated as the first-line therapy for the treatment or prevention of an infection, cephalosporins are often avoided if the patient has a penicillin allergy listed.^1-7