Antibiotic allergy de-labelling has become a focus of international antimicrobial stewardship programs. In Australia, over two million people report an antibiotic allergy, with one in ten in hospitals reporting an allergy to penicillin. As many as 85% of these allergies can be safely tested and de-labelled.³ As outlined in the Antimicrobial Stewardship Clinical Care Standard, antibiotic allergies should be accurately assessed and documented to allow for optimal antimicrobial prescribing. It is known that patients labelled with a penicillin allergy have increased prevalence of Clostridioides difficile infection (CDI), methicillin-resistant Staphylococcus aureus (MRSA) and vancomycin-resistant enterococci (VRE), and have longer hospital stays.¹ Inaccurate penicillin allergy labels have been associated with increased use of broad-spectrum antibiotic use and inappropriate prescribing.² Due to the success of the Better Care Victoria project that implemented an inpatient antibiotic allergy assessment and de-labelling service at Austin Health and Peter MacCallum Cancer Centre, Safer Care Victoria chose to expand the project to other health services in the state. 

A change package was developed to support other Victorian health services with the roll out of an inpatient penicillin allergy assessment and de-labelling program. 

The core activities undertaken during the planning phase of this project included:  

1. Encouraging health services to collect four weeks of baseline data prior to the project commencement
2. Implementing process mapping to identify key stakeholders for engagement and to determine stages in the patient’s journey where penicillin allergies could be identified, assessed and de-labelled
3. Establishing governance structures and stakeholder engagement mechanisms to enable project success
4. Development of local guidelines, including inclusion criteria for penicillin allergy testing
5. Education for clinicians. 

At the time, limited support and services were available to de-label low risk penicillin allergies in other health services in Victoria. 

Key measures for the project included percentage of patients with:

• No risk of a true penicillin allergy that have their allergy directly de-labelled
• Low risk of a true penicillin allergy that have their allergy de-labelled following an oral challenge
• A documented penicillin allergy in the medical record with the active ingredient, the date of the reaction, its nature and severity specified.

Safer Care Victoria found the following barriers in implementing allergy de-labelling services in Victorian hospitals: 

• Varying levels of clinician knowledge about penicillin allergy labels 
• Lack of expertise and confidence in implementing a penicillin allergy de-labelling service 
• Low priority to assess antibiotic allergies
• Overreporting of penicillin allergies by patients due to experiencing a side effect to a penicillin, childhood reactions, family history, miscommunication and overcaution. 

Safer Care Victoria collaborated with health services to use the Model for Improvement to implement penicillin allergy de-labelling at 12 health facilities including rural, regional and metropolitan hospitals. Safer Care Victoria ran three in-person learning sessions and three health service-based action periods, where changes were tested and adapted. The participating sites maintained contact with each other and Safer Care Victoria, and regularly shared wins, challenges and learnings.

Of the 12 sites, 11 have implemented a guideline to conduct inpatient penicillin de-labelling.

The program has: 

• Achieved a 25% increase in access to comprehensive allergy assessment for hospitalised patients 
• Developed a toolkit to share learnings. 

System benefits:
Safer Care Victoria is partnering with the international Network of Antibiotic Allergy Nations (iNAAN) to form the Check Again Network. The Check Again Network will scale and spread the work of the Collaborative to additional Victorian sites and create the opportunity for services to share wins, challenges, and learnings. 

The Therapeutic Guidelines recommend that following adequate source control, antimicrobial therapy can continue for a further duration of 4 to 7 days for intra-abdominal infections, depending on clinical response.¹ Despite these recommendations, the antimicrobial stewardship (AMS) team at Concord Hospital identified that their surgical patients were often prescribed prolonged courses of broad-spectrum antimicrobials. The AMS Clinical Care Standard states that antimicrobial therapy should be regularly reviewed for ongoing need, appropriate antimicrobial spectrum of activity, dose, frequency and route of administration. Benchmarking found antibiotic plans for these surgical patients often missed the key indicators. 

Concord Hospital participates in the National Antimicrobial Prescribing Survey (NAPS) annually. The results from the latest NAPS were used to establish the extent of the issue and inform strategies to address the high volume of inappropriate antimicrobial use in surgical patients.

Evaluation of the prescribing data found only 60% of antimicrobial prescriptions for colorectal patients were appropriate and just 71.4% of these prescriptions were appropriate for vascular patients. Overall appropriateness was below the overall national principal referral hospital average of 72.9%.

The AMS team explored the underlying drivers for the high rate of inappropriate antimicrobial prescribing in surgical specialties. Through discussions, it was found that: 

• Due to the structure of surgical teams, junior ward-based doctors were the point of first contact and lacked authorisation to make substantial changes to antimicrobial choices
• Limited understanding of surgical procedural resulted in antibiotic de-escalation choices being delayed, undocumented antibiotic durations or review dates, and inter-team conflict
• There was a perception among surgical teams that AMS teams under-appreciate surgical complexities, and antimicrobial prescribing recommendations are based on inadequate parameters and understanding of surgical procedures.

The AMS team initiated weekly collaborative meetings attended by a range of staff, including senior surgical staff from the Vascular, Colorectal and Upper Gastrointestinal (GI) Surgery teams. Discussion focused on the surgical context including recent procedures, relevant microbiology, and devising an antibiotic plan.

The meetings were facilitated by electronic prescribing and an innovative locally developed tool called the Cerner LiveAMS Monitoring Page (AMS mPage). The tool provides a live, direct feed from eMeds into a summary dashboard, enabling identification of all patients on antibiotic therapy. It integrates key information, including microbiology results, medication orders (such as indication, duration, prior antibiotic use and known drug allergies). The tool allowed the AMS and surgical teams to make real-time changes to prescriptions directly from the meeting room. 

The project has achieved:

• Improved rates of appropriate antimicrobial prescribing from 68% appropriateness to 85% to 100% appropriate in the last five years (2019 – 2023) for the surgical specialties 
• Improved patient outcomes
• Increased scope of AMS service.

Other outcomes included: 

• Increased rapport between the surgical department and the AMS team – the meetings are championed by the heads of surgical departments
• Greater collaboration with other surgical departments – the initiative has been extended to include Plastic Surgery and the Breast and Endocrine Surgery units.