A qualitative analysis of antibiotic allergy documentation practices revealed that barriers to properly documenting antibiotic allergies led to a surplus of suboptimal and inappropriate antibiotic prescriptions by physicians and pharmacists, according to a study published in Annals of Family Medicine.
When a patient does not receive a certain antibiotic drug due to a documented allergy, the second-choice treatment they receive is more likely to cause superinfections and longer recovery times. Researchers viewed antibiotic resistance as a growing threat to public health; they hypothesized that many patients who are listed as allergic to certain antibiotics may not actually have a life-threatening type 1 reaction and should be given their provider’s first-choice antibiotic to avoid the dangers associated with second-choice treatments.
Four focus groups with a total of 44 participants from diverse backgrounds (34 family physicians, 10 pharmacists) met in South Limburg, the Netherlands to discuss the magnitude and origins of inappropriate allergy documentation as well as potential solutions. The discussions were facilitated and recorded by an independent moderator and lasted approximately 45 to 60 minutes.
Three main themes were identified following the focus groups: magnitude and awareness of inappropriate antibiotic allergy documentation; origin of the problem; and approaches for addressing it.
Participants stated that they frequently encounter documented antibiotic allergies but concluded that most are actually adverse effects as type 1 reactions are rare. One participant stated that the word “allergy” can often be replaced with “side effect.” Some participants voiced their awareness of how patients with a documented allergy have limited treatment options, but others were unaware of how this limitation can lead to consequences such as antibiotic resistance or increased health care costs when using second-choice antibiotics.
“Because of incomplete documentation, family physicians feel they often have no other option than to prescribe alternative, second-choice antibiotics. The large-scale consequences of using these broad-spectrum antibiotics were not generally recognized,” researchers said.
Many electronic health records (EHRs) do not lend themselves to proper antibiotic allergy documentation, according to the study authors. In some systems, it is impossible to separate adverse effects from allergies due to lack of nuanced options. In other systems, allergies can be found in numerous places in the EHR, creating confusion.
Pharmacists who participated in the study stated that they sometimes intentionally misuse the system and document a false allergy when a patient does not want a particular brand or drug due to adverse effects or cost.
Participants cited a lack of communication between general practices, pharmacies, and hospitals as a barrier to proper documentation. They also noted that most antibiotic allergies are self-reported by patients; this is problematic, since most patients do not understand the definition nor the consequences of an antibiotic allergy. However, some participants stated that clinicians also had insufficient knowledge of the definition of an antibiotic allergy and called for a clear definition of an adverse effect vs an allergy.
During the focus group sessions, clinicians developed potential remedies for improper antibiotic allergy documentation. Several changes to EHRs were proposed; participants called for separate reporting of adverse effects and allergies. According to participants, documented allergies should be accompanied by a detailed description of the reaction.
To improve communication between providers, participants suggested that physicians and pharmacists develop a work agreement to alert each other if a drug was stopped or switched, and the reason(s) why. To avoid misuse of allergy documentation on EHRs, participants called for a separate indicator in the system if a patient does not want a particular drug due to cost or other reasons.
Participants suggested that a toolkit be developed to streamline pre-existing EHRs with faulty documentation but acknowledged that this would be a considerably large volume of work. In addition to stating a need for a clear definition of an adverse effect vs an allergy, participants suggested that there should be an algorithm for documenting both of these events to prevent future inconsistencies.
De Clerq K, Cals J, de Bont E. Inappropriate antibiotic allergy documentation in health records: a qualitative study on family physicians’ and pharmacists’ experiences. Ann Fam Med. 2020;18(4):326-333.