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Improving clinical outcomes in patients with methicillin-sensitive Staphylococcus aureus bacteremia and reported penicillin allergy.
Clin Infect Dis. 2015 May 19;
Authors: Blumenthal KG, Parker RA, Shenoy ES, Walensky RP
Abstract
BACKGROUND: Methicillin-sensitive Staphylococcus aureus (MSSA) bacteremia is a morbid infection. First-line MSSA therapies (nafcillin, oxacillin, cefazolin) are generally avoided in the 10% of patients reporting penicillin allergy, but most of these patients are not truly allergic. We used a decision tree with sensitivity analyses to determine the optimal evaluation and treatment for patients with MSSA bacteremia and reported penicillin allergy.
METHODS: Our model simulates three strategies: 1) no allergy evaluation; give vancomycin (Vanc); 2) allergy history-guided treatment; if history excludes anaphylactic features, give cefazolin (HX-Cefaz); and 3) complete allergy evaluation with history-appropriate penicillin skin testing; if skin test negative, give cefazolin (ST-Cefaz). Model outcomes included 12-week MSSA cure, recurrence, and death; allergic reactions including major, minor, and potentially iatrogenic; adverse drug reactions (ADRs).
RESULTS: Vanc results in the fewest patients achieving MSSA cure and the highest rate of recurrence: (Vanc 67.3%/14.8% vs HX-Cefaz 83.4%/9.3% and ST-Cefaz 84.5%/8.9%) as well as the greatest frequency of allergic reactions (Vanc 3.0% vs HX-Cefaz 2.4% and ST-Cefaz 1.7%) and highest rates of ADRs (Vanc 5.2% vs HX-Cefaz 4.6% and ST-Cefaz 4.7%). Even in a "best case for Vanc" scenario, Vanc yields the poorest outcomes. ST-Cefaz is preferred to HX-Cefaz though sensitive to input variations.
CONCLUSIONS: Patients with MSSA bacteremia and a reported penicillin allergy should have the allergy addressed for optimal treatment. Full allergy evaluation with skin testing seems preferred although more data are needed.
PMID: 25991471 [PubMed - as supplied by publisher]