The Operating Theatre Journal February 2022

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Are you sure you are allergic to penicillin? Professionalsand patients are urged to double-checkPublished on 20 January 2022doi: 10.3310/alert_48839Millions of people in the UK have penicillin allergy recorded in theirmedical notes. Many of them are not truly allergic. New researchhighlights the importance of both doctors and patients discussingrecorded penicillin allergies.Penicillins are first-line treatment for many infections. People with apenicillin allergy listed in their medical records will not receive them.This keeps people with a true allergy safe. However, it means thatpeople who are not allergic will receive second choice antibiotics iftheir notes are incorrect. This can mean longer hospital stays and morerisk of antibiotic-resistant bacteria.This research explored patients’ and physicians’ views on penicillinallergy. It found that both groups were often unsure if the allergy wastrue. There was also confusion over the difference between a sideeffect and an allergy. Patients tended not to question the allergy onceit was in their notes. Similarly, doctors were often reluctant to overridethe allergy record in case of an allergic reaction.Having penicillin allergy wrongly included in medical notes has negativeconsequences. The study is part of a larger project designed to see iftesting for penicillin allergy and removing incorrect records improvespatient health outcomes and antibiotic use.Currently, few GPs have access to testing for penicillin allergy or knowhow to refer people. These results show the need for more widespreadcommunication about testing. More testing would mean that manypeople could safely have penicillin allergy removed from their records.Further information on penicillin allergy is available on the NHS website.What’s the issue?Antibiotics, particularly penicillins, are used to treat bacterialinfections. Around 1 in 15 people have an allergy to antibiotics listedin their medical records. Three million people in the UK are unable toaccess highly effective penicillins.Most reported reactions to penicillins are mild. However, true allergicreactions can be severe, and include breathing difficulties and loss ofconsciousness.Previous research has suggested that as few as 1 in 10 people witha penicillin allergy listed in their medical records are truly allergic.Occasionally, symptoms of the infection being treated (such as a rash)can be confused with an allergic reaction. Or side effects might bethought to be an allergy. The most common side effects of antibioticsaffect the digestive system (vomiting, nausea, diarrhoea). They areusually mild and stop when treatment finishes. Symptoms or side effectscan lead to an allergy being incorrectly listed in medical records.Penicillin is an effective first-choice antibiotic. People with penicillinallergy listed in their records are given the next best medication.Allergies are included in medical records to safeguard people againsthaving a reaction. However, having a penicillin allergy listed in medicalrecords is linked with negative outcomes. They include longer hospitalstays, more antibiotic prescriptions, an increased risk both of surgicalsiteinfection and infection with antibiotic-resistant superbugs, anddeath. It is therefore important to ensure the information is accurate.The National Institute for Health and Clinical Excellence (NICE) asksclinicians to ‘double check’ patients with a penicillin allergy recorded.This is because another antibiotic might not be as effective for theirillness. In addition, many alternatives to penicillin (broad-spectrumantibiotics) act against a wider range of bacteria. They are more likelyto promote antibiotic resistance. Progress towards new antibiotics hasbeen slow.This study explored clinicians’ and patients’ views of penicillin allergy,and of testing for it.What’s new?Researchers interviewed 31 patients with documented penicillinallergy in the North of England. They also interviewed 19 primary carephysicians both with and without experience of dealing with penicillinallergy.Five main themes emerged from the interviews.1. Patients’ understanding of allergyMany people were diagnosed with allergy a long time ago. They weremore convinced of their allergy if symptoms occurred immediatelyafter taking penicillin, or were very severe. Some questioned if allergywas hereditary. Many were unclear about the difference between sideeffects and allergies.2. Impact of allergy on patientsPeople who believed themselves to have a true allergy typicallyreminded healthcare professionals of their allergy and checkedmedicines for penicillin. People who were at risk of recurrent infectionsworried more about running out of antibiotic options than those whorarely took antibiotics.3. Doctor-patient interactionMost patients accepted the diagnosis of allergy without question anddid not discuss it with their physician. Some would take advice fromtheir physician about whether allergy testing would be beneficial.4. Doctors’ uncertainties about diagnosesDoctors said they routinely checked medical records for allergies, andvalued reminders on the electronic system. Some also checked withthe patient. Others noted that the on-screen system did not distinguishbetween side effects and allergies. This made several doctors doubtallergy status. Physicians also queried how the diagnosis was originallymade and whether it was based on family history.Most doctors were aware of the over-diagnosis of penicillin allergy. Asevere reaction (anaphylaxis) was clear-cut but some symptoms (suchas rash) made allergy difficult to diagnose.5. Prescribing decisionsDoctors did not find it difficult to source alternative antibiotics whenthere was only one allergy. Even when they doubted the recordedallergy, they often avoided prescribing penicillin. Some doctorschallenged the recorded allergy, for instance where penicillin was thebest choice. They discussed it with the patient and came to a decisiontogether after reviewing the medical history.Some doctors had referred patients for allergy tests, though most wereuncertain about the criteria needed and what testing involved. Doctorsrarely initiated discussions about the negative consequences of having apenicillin allergy recorded in medical notes. They said this was becauseit would not affect the patients’ day-to-day lives.The research team concluded that both doctors and patients should bemore aware of the negative consequences of having penicillin allergyincorrectly included in medical notes.Why is this important?Diagnosing penicillin allergy is clinically difficult and medical recordsare often incomplete. Doctors tend not to prescribe penicillin if anallergy is noted, even when they doubt it is a true allergy.The interviews identified gaps in patients’ understanding of penicillinallergy and how it differs from side effects. More discussions betweendoctors and patients would be helpful. (Continues on page 25)24 THE OPERATING THEATRE JOURNAL www.otjonline.com
(Continued)New Type of Medical HelicopterProvides Intensive Care in TransitThe research concluded that doctors as well as patients need to beconvinced of the negative consequences of keeping an inaccuratediagnosis in records. Some felt it was an issue in the hospital setting,rather than in primary care. Highlighting the negative impacts couldlead to more open discussions between patients and their GPs.The benefits of testing for penicillin allergy also need to be stressed,the study found. Doctors need more information about how to arrangetesting for patients.What’s next?Both doctors and patients need to understand the potential harmsassociated with having penicillin allergy wrongly noted in medicalrecords. Healthcare professionals could be encouraged to supply moredetail in medical records about the initial reaction to penicillin. Theyalso need support to de-label low-risk patients in primary care. Decisionaids and algorithms might help to establish whether a medication hascaused harm, and whether testing is needed.The current study was part of a larger project called ALABAMA (AllergyAntibiotics and Microbial Resistance). Other research by the same teamis aiming to find clinically- and cost-effective ways of correcting a falserecord about penicillin allergy. As part of this work, the researchersare looking to make allergy testing more efficient. It currently requirestwo visits. The team are exploring ways of testing for allergy in a singlevisit.You may be interested to readThis NIHR Alert is based on: Wanat M, and others. Management ofpenicillin allergy in primary care: a qualitative study with patients andprimary care physicians. BMC Family Practice 2021;22:112Another paper from the same team: Wanat M, and others. Patient andprimary care physician perceptions of penicillin allergy testing andsubsequent use of penicillin-containing antibiotics: a qualitative study.The Journal of Allergy and Clinical Immunology: In Practice 2019;7:1888-1893Funding: This work was funded by the NIHR under its ProgrammeGrants for Applied Research Programme.Conflicts of Interest: The study authors declare no conflicts of interest.Disclaimer: NIHR Alerts are not a substitute for professional medicaladvice. They provide information about research which is funded orsupported by the NIHR. Please note that views expressed in NIHR Alertsare those of the author(s) and reviewer(s) and not necessarily those ofthe NHS, the NIHR or the Department of Health and Social Care.Karolinska University Hospital will be the first in Sweden to have a newtype of medical helicopter that can provide the sickest patients withadvanced care, even in the air. The helicopter can bring patients fromall over the country to Karolinska.A contract for the operation and delivery of an Agusta Westland 139(AW 139) helicopter has been signed by the supplier, Babcock, andKarolinska. Karolinska will get access to a temporary helicopter inMarch, 2022, and at the beginning of 2023, the permanent helicopterwill be delivered.- Karolinska will be the first hospital in Sweden to have this type ofhelicopter, which is unique, as the on-board staff can provide thesickest patients with on-board medical care in a way that has not beenpossible until now, such as ECMO care, says Lars Falk, operationalmanager of Intensive Care and Transport, and continues:- With the new helicopter, we can reach hospitals faster because wedon’t have to reload like we do now when flying planes.Another advantage of the AW 139, which is considerably larger, heavier,and has much more space than a regular ambulance helicopter, is thatit is built to withstand very severe weather conditions.- In addition, it has its own de-icing system that allows it to withstandsevere winter weather and storms. All in all, the helicopter basicallyfunctions as a flying intensive care unit, says Lars Falk.HideBabcock Agusta Westland (AW 139)• Can fly with a total weight of 7 tonnes• Rotor diameter is 13.8 metres• Length, 16.7 metres• Space for 4 staff and 1 patient on board• Extra-large windows for maximum visibility during missionsGI Supply Receives CE Mark for its EverLift® Submucosal Lifting AgentNew EverLift® medical device now available to physiciansacross EuropeGI Supply Inc. today announced its EverLift® Submucosal Lifting Agenthas been awarded a CE Mark and is now available for use by physiciansacross Europe. EverLift is a new device for the lift of polyps, adenomas,early-stage cancers and other gastrointestinal lesions prior to theirexcision with a snare or other appropriate endoscopic device1.EverLift facilitates endoscopic resection procedures such as endoscopicmucosal resection (EMR) or endoscopic submucosal dissection (ESD),during examinations in the upper and the lower gastrointestinal tract.EverLift is GI Supply’s first medical device to be awarded a CE Markunder the new EU Regulation 2017/745 on Medical Devices (MDR).EverLift gained FDA clearance in October 2020.EverLift is the only pre-filled Submucosal Lifting Agent available inboth 5mL and 10mL syringes, providing physicians with the flexibilityto use only what they need whether lifting small or large lesions. Inaddition, the sterile pre-filled syringe reduces the time and infectionrisk associated with preparing a hospital-mixed solution.The darker blue colour of EverLift is used to identify the perimeter oflesions enabling a safe and complete resection, reducing the risk ofrecurrent lesions. Following resection of a lesion, the darker colourhelps endoscopists identify potential injuries to the muscle layer.“Lifting agents aid in safer resections for patients. EverLift providesa pliable yet reliable cushion for resection and darker blue hues. Thesingle serve dosing helps reduce waste for everyday polypectomies.” –Dr. Taavi Reiss, Assistant Professor of Clinical Medicine LSU Health andDirector of Interventional GI Metropolitan Gastroenterology Associates.EverLift is cellulose based, creating a hypertonic solution with anabsorption rate slower than other currently available agents2. EverLiftprovides gastroenterologists with a long and stable lift during theirresection procedures.“This is an effective lifting agent for endoscopic resection that isoffered in convenient and cost-effective packaging.” – Prof. DouglasRex, Director of Endoscopy at Indiana University Hospital, Indianapolis.“The CE Mark for EverLift enables us to reach more physicians aroundthe world. Many gastroenterologists will be familiar with our Spot®Ex Endoscopic Tattoo, and we have used our extensive experience ininjection solutions to develop a unique lifting agent which will enhancetheir ability to safely resect lesions,” said GI Supply Senior MarketingManager Simon Humphrey-Adam.View the product video here: bit.ly/OTJEverLiftFurther information contact: Simon Humphrey-Adam, InternationalMarketing Manager, s.humphrey-adam@gi-supply.com, 07974 319 541www.gi-supply.com.1. EverLift Instruction for Use G55-006 Rev 08, Nov 2021; G59-007Rev 07, Nov 20212. Based on ex-vivo bench top studies and not in clinical use.Data on fileFind out more 02921 680068 • e-mail admin@lawrand.com Issue 377 February 2022 25
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