Adaptation of the WHO AWaRe (Access, Watch, Reserve) antibiotic classification to support national antimicrobial stewardship priorities in the UK: findings from a modified Delphi approach to achieve expert consensus.

Objectives: In 2017, the WHO introduced the AWaRe (ccess, tch and serve) classification of antibiotics to support antibiotic stewardship (AMS) at local, national and global levels. We assessed the categorization of each of the antibiotics for systemic use for antimicrobial stewardship and quality improvement practice across primary and secondary care in the UK, proposing a nationally adapted UK-AWaRe classification.

Methods: A four-stage modified Delphi survey was conducted to review the AWaRe classifications in light of antibiotic resistance profiles, antibiotic use and stewardship practice in the UK.

Penicillin allergy de-labelling implementation intervention in a UK hospital: a process evaluation, the patient experience.

Background: Penicillin allergy (penA) records are common, but true penA is rare. PenA records are associated with broad spectrum antibiotic prescribing and negative patient outcomes. We developed a behavioural intervention package to support inpatient penicillin allergy de-labelling (PADL) delivered by a multi-profession non-allergist workforce to remove incorrect penA records from medical and surgical adult inpatients in a UK hospital.

Procalcitonin to guide antibiotic use during the first wave of COVID-19 in English and Welsh hospitals: integration and triangulation of findings from quantitative and qualitative sources.

Aim: To integrate the quantitative and qualitative data collected as part of the PEACH (Procalcitonin: Evaluation of Antibiotic use in COVID-19 Hospitalised patients) study, which evaluated whether procalcitonin (PCT) testing should be used to guide antibiotic prescribing and safely reduce antibiotic use among patients admitted to acute UK National Health Service (NHS) hospitals.

Design: Triangulation to integrate quantitative and qualitative data.

Setting And Participants: Four data sources in 148 NHS hospitals in England and Wales including data from 6089 patients.

Description of the combined evidence-based, theory-based and person-based approaches used to develop a behavioural intervention package to support non-allergist healthcare workers to remove incorrect penicillin allergy records from medical and surgical adult inpatients in a UK hospital.

Objectives: To develop a behavioural intervention package to support non-allergist healthcare workers (HCWs) to remove incorrect penA records from medical and surgical adult inpatients. This paper describes the development of the penicillin allergy de-labelling (PADL) intervention and the implementation intervention that will support non-allergist-delivered PADL.

Design: We combined evidence-based, theory-based and person-based approaches.

Direct oral penicillin challenge in secondary care with low-risk patients: the SPACE mixed-methods study with cost-effectiveness analysis.

Background: One in five inpatients carries a penicillin allergy label. However, 90-95% of labels are incorrect. Penicillin allergy labels lead to increased risk for serious hospital infections and longer hospital stay and are associated with higher estimated healthcare costs.

Patients' acceptance of a penicillin allergy de-labelling programme in primary care: a qualitative study.

Background: About 6% of the UK general practice population has a record of a penicillin allergy but fewer than 10% of these people are likely to be truly allergic. Consequently, a significant portion of the population is denied first-line antibiotics. The ALlergy AntiBiotics And Microbial resistAnce (ALABAMA) trial aimed to determine if a penicillin allergy assessment pathway (PAAP) was safe and effective in de-labelling patients as allergic and improving antibiotic prescribing and patient health outcomes.

Healthcare professionals' experiences of de-labelling erroneous penicillin allergy records in general practice: a qualitative study.

Background: Penicillin allergy (PenA) prevalence is approximately 6%, but fewer than 10% of these people are expected to be truly allergic. Consequently, a significant proportion of the population are prescribed alternative antibiotics with potential increased risk of acquiring multi-drug resistant bacteria and worse health outcomes. The ALlergy AntiBiotics And Microbial resistAnce (ALABAMA) trial aimed to determine if a penicillin allergy assessment pathway (PAAP) initiated in primary care, is effective in de-labelling erroneous records, improving antibiotic prescribing and patient outcomes.

Narrative review of recent developments and the future of penicillin allergy de-labelling by non-allergists.

This article outlines recent developments in non-allergist delivered penicillin allergy de-labelling (PADL), discusses remaining controversies and uncertainties and explores the future for non-allergist delivered PADL. Recent developments include national guidelines for non-allergist delivered PADL and validation of penicillin allergy risk assessment tools. Controversies remain on which penicillin allergy features are low risk of genuine allergy.

A rapid literature review of the impact of penicillin allergy on antibiotic resistance.

Background: Antimicrobial resistance (AMR) is caused by the use and misuse of antibiotics. AMR is a global health concern, to which penicillin allergy (penA) labels appear to contribute. Patients who have penA labels are treated with non-penicillin antibiotics and receive more antibiotics when compared with patients without penA.

Combination therapy versus monotherapy: retrospective analysis of antibiotic treatment of enterococcal endocarditis.

Background: Guidelines suggest treating fully penicillin-susceptible Enterococcus faecalis strains causing infective endocarditis with amoxicillin combined with gentamicin or ceftriaxone, but clinical evidence to support this practice is limited and monotherapy cohorts were excluded from studies. We describe antibiotic treatment, complications, and outcomes in patients with Enterococcus faecalis infective endocarditis, specifically comparing monotherapy versus combination therapy.

Methods: Retrospective analysis of prospectively collected cohort of patients with definite or possible infective endocarditis from 2 English centres between 2006 and 2021.

Characteristics, risk factors and clinical impact of penicillin and other antibiotic allergies in adults in the UK General Practice: A population-based cohort study.

Objective: To assess the characteristics, risk factors and clinical impact of penicillin and other antibiotic allergy labels in general practice in the UK.

Design: Population-based cohort study.

Setting: Primary care in the UK, 2000-2018.

Utilising primary care electronic health records to deliver the ALABAMA randomised controlled trial of penicillin allergy assessment.

Background: Use of electronic health records (EHR) to provide real-world data for research is established, but using EHR to deliver randomised controlled trials (RCTs) more efficiently is less developed. The Allergy AntiBiotics And Microbial resistAnce (ALABAMA) RCT evaluated a penicillin allergy assessment pathway versus usual clinical care in a UK primary care setting. The aim of this paper is to describe how EHRs were used to facilitate efficient delivery of a large-scale randomised trial of a complex intervention embracing efficient participant identification, supporting minimising GP workload, providing accurate post-intervention EHR updates of allergy status, and facilitating participant follow up and outcome data collection.

A retrospective propensity-score-matched cohort study of the impact of procalcitonin testing on antibiotic use in hospitalized patients during the first wave of COVID-19.

Background: Procalcitonin (PCT) is a blood marker used to help diagnose bacterial infections and guide antibiotic treatment. PCT testing was widely used/adopted during the COVID-19 pandemic in the UK.

Objectives: Primary: to measure the difference in length of early (during first 7 days) antibiotic prescribing between patients with COVID-19 who did/did not have baseline PCT testing during the first wave of the pandemic.

Factors influencing implementation and adoption of direct oral penicillin challenge for allergy delabelling: a qualitative evaluation.

Background: Over 95% of penicillin allergy labels are inaccurate and may be addressed in low-risk patients using direct oral penicillin challenge (DPC). This study explored the behaviour, attitudes and acceptability of patients, healthcare professionals (HCPs) and managers of using DPC in low-risk patients.

Methods: Mixed-method, investigation involving patient interviews and staff focus groups at three NHS acute hospitals.

Introducing the UK Antimicrobial Registry (UKAR) study: providing real world data on new antimicrobials to support antimicrobial stewardship and tackle antimicrobial resistance.

The UK Antimicrobial Registry (UKAR) has been developed to capture data on real world usage of antimicrobial agents with an initial focus on those used to treat drug-resistant infections. Several industry partners have committed support for the study, which is included in the National Institute for Health and Care Research (NIHR) portfolio in England with similar arrangements in the three devolved UK nations. The two antimicrobials in the National Institute for Health and Care Excellence (NICE) subscription model pilot (cefiderocol and ceftazidime/avibactam) are included in the UKAR and future expansion of work in this area is planned.

The appropriateness of penicillin allergy de-labelling by non-allergist clinical ward teams.

Objectives: We aimed to assess the appropriateness of penicillin allergy (PenA) assessment conducted by clinical teams and to review the safety of subsequent exposure of these patients to penicillin.

Methods: Opportunistic, prospective observational study of usual clinical care, between 16 May 2023 and 14 August 2023, of inpatients with a PenA and requiring antibiotics, in a 750-bed hospital in England. To assess the appropriateness of management, PenA patients prescribed penicillins were grouped into risk categories using a validated antibiotic allergy assessment tool: eligible for de-label on history alone (direct de-label; DDL), eligible for direct oral challenge (DOC), high risk or unable to obtain history.

Evidence of quality of life for hospitalised patients with COVID-19: a scoping review.

Background: Information on the quality of life of people hospitalised with COVID-19 is important, both in assessing the burden of disease and the cost-effectiveness of treatments. However, there were potential barriers to collecting such evidence.

Objective: To review the existing evidence on quality of life for people hospitalised with COVID-19, with a focus on the amount of evidence available and methods used.

Eliciting the barriers and enablers towards anaesthetists giving penicillin-based antibiotic prophylaxis to low-risk patients who have had their penicillin allergy label removed as part of a preoperative delabelling process.

Background: Some penicillin allergy labels can be removed by non-allergy specialists by direct oral challenge, but there is reluctance amongst anaesthetists to give penicillin to these patients. We aimed to assess anaesthetist beliefs about giving penicillin to patients delabelled by direct oral challenge.

Methods: A survey, developed using the Theoretical Domains Framework, was circulated to anaesthetists within a regional research network in England.

Experiences of an inpatient penicillin allergy de-labelling pathway: capturing the patient voice.

Background: Non-allergist-delivered penicillin allergy de-labelling (PADL) is supported by UK and other national guidelines but is not yet routine practice in UK hospitals. Those who have undergone PADL report high rates of acceptance, but it is unknown why some continue to avoid penicillin, and why some decline testing.

Objectives: To explore the experiences of patients recently approached for penicillin allergy (penA) assessment and de-label by non-allergists in a UK hospital to determine the barriers and enablers to patient acceptance of PADL.

Non-allergist healthcare workers views on delivering a penicillin allergy de-labelling inpatient pathway: identifying the barriers and enablers.

Background: Non-allergist delivered PADL is supported by UK and World Health Organization guidelines but is not yet routine in UK hospitals. Understanding the views of healthcare workers (HCWs) on managing patients with penA records and exploring perspectives on delivering a PADL inpatient pathway are required to inform the development of non-allergist delivered PADL pathways.

Objective: To explore the perspectives of non-allergist HCWs working in medical specialties on managing patients with penA records, and to explore the enablers and barriers to embedding PADL as a standard of care for inpatients.

Penicillin allergy de-labelling by non-allergists: a comparison of testing protocols.

Optimizing penicillin allergy de-labelling (PADL) to ensure patients with an incorrect penicillin allergy record are de-labelled with minimal patient harm is important for antibiotic stewardship. The heterogeneity of inclusion and exclusion criteria in the published penicillin allergy testing protocols risks suboptimal delivery of PADL. We compared the similarities and the differences between non-allergist-delivered PADL testing protocols and make suggestions for harmonization.

Feasibility, Effectiveness and Safety of Elastomeric Pumps for Delivery of Antibiotics to Adult Hospital Inpatients-A Systematic Review.

Elastomeric infusion pumps (EMPs) have been implemented in many fields, including analgesia, chemotherapy and cardiology. Their application in antimicrobials is mainly limited to the outpatient setting, but with a need to optimise inpatient antimicrobial treatment, the use of EMPs presents a potential option. This review aimed to identify if the use of EMPs within an inpatient setting is feasible, effective and safe for antimicrobial use.