Author Identifier

Annabelle Arnold

http://orcid.org/0000-0002-2242-3018

Date of Award

2024

Document Type

Thesis

Publisher

Edith Cowan University

Degree Name

Doctor of Philosophy

School

School of Nursing and Midwifery

First Supervisor

Linda Coventry

Second Supervisor

Mandie Foster

Third Supervisor

Michaela Lucas

Fourth Supervisor

Michelle Trevenen

Abstract

Antimicrobial resistance is rising while new drug development declines, making antimicrobial stewardship crucial for optimizing use, preventing resistance, and improving patient outcomes. Antibiotics are vital for bacterial infections, but overuse and inappropriate prescribing have contributed to resistance. Although 5-35% of the global population reports β-lactam allergies, over 90% of reports are inaccurate. Adults have the highest prevalence; however, these labels are often acquired in childhood, with a notable increase among children recently. Unverified allergy labels hinder antimicrobial stewardship, leading to longer hospital stays, alternative prescribing, and a higher risk of adverse events.

This thesis sought to evaluate current evidence regarding antibiotic allergy and its impact on clinical outcomes for both adults and children and performed a retrospective study investigating the prevalence of antibiotic allergy within a paediatric setting and its clinical implications. The knowledge gained will inform changes in practice to improve understanding, reporting, and delabeling strategies for drug allergies, ultimately enhancing clinical outcomes. Currently, there is limited data available in this paediatric context.

The systematic review summarized the impact of patient-reported antibiotic allergies on clinical outcomes and assessed strategies to effectively evaluate and remove these labels. Following PRISMA guidelines, the review appraised all studies and performed a narrative synthesis, identifying four themes: prevalence of antibiotic allergy, impact on antimicrobial prescribing, impact on clinical outcomes, and delabeling strategies. Among 32 studies with 1,089,675 participants, the prevalence of reported antibiotic allergy ranged from 5-35%. Patients with reported allergies had poorer adherence to prescribing guidelines in 30-60% of patients, greater use of alternative reserved antibiotics, and lower use of beta-lactams. Antibiotic allergy delabeling was recommended to improve clinical outcomes.

A retrospective study at a paediatric tertiary hospital in Western Australia reviewed 1,590 inpatient admissions under antimicrobial stewardship (AMS) between 2017-2019. Data included documented antibiotic allergies, prescriptions, diagnoses, specialties, hospital stays, Intensive Care admissions (ICU) admissions, and readmissions. Among the patients, 6.6% reported at least one antibiotic allergy, mainly to unspecified penicillins. Allergy prevalence increased with age, with no gender effect seen. Allergy prevalence was higher in oncology and lower in general surgery children. Patients with beta-lactam allergy labels received more quinolones, lincosamides, aminoglycosides, and metronidazole, while those without received more β-lactams. Children with allergy labels had longer hospital stays ([IQR] 7.0 [4.0, 15.0] days [IQR] 5.0 [3.25, 11.0] days) however, there was no link between antibiotic labeling and rates of readmission.

A comparative analysis was conducted using the above retrospective study and previous study that collected similar data in a general inpatient cohort, to ascertain whether there was a greater impact on clinical outcomes for the AMS cohort. This was confirmed, evidenced by longer hospital stays and greater utilisation of reserved antibiotics.

There is substantial evidence that shows antibiotic allergy labels significantly impact patient outcomes and that systematic assessment, or "delabeling," improves clinical management. This thesis highlights that antibiotic allergy labels in children, assessed through AMS, lead to longer hospital stays and greater use of reserve antibiotics. Given recent advances in delabeling, early intervention can potentially improve outcomes for children with these labels, benefitting both paediatric and adult healthcare services.

DOI

10.25958/vqej-ag73

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