Infection
Conditions
Keywords
penicillin, allergy, antimicrobial, resistance
Brief summary
ALBAMA study is designed to find out if the effects of Penicillin allergy assessment pathway (PAAP) intervention is on penicillin prescribing
Detailed description
* Antibiotics are important medicines for fighting infections caused by bacteria. Their widespread use has caused a worrying rise in antibiotic resistant bacteria, which are bacteria that are harder to control or kill with antibiotics. Patients with infections caused by antibiotic resistant bacteria are often ill for longer and have an increased risk of serious harm, including death. The spread of resistant bacteria can be slowed down by using antibiotics more carefully. Penicillins are an important group of antibiotics that are recommended treatment for many infections. Doctors will avoid prescribing penicillin for their patients who have a penicillin allergy label in their health records. These patients are usually prescribed different types of antibiotics for their infections. There is concern that these non-penicillin antibiotics may not work as well as penicillins, may cause more side-effects (including killing more of the body's helpful bacteria), and may be more expensive. * About 9 out of 10 people who have a record of penicillin-allergy are found to be not truly allergic to penicillin when thoroughly tested. This means they could safely take penicillins. The aim of ALABAMA is to find out if people with a penicillin-allergy record in their GP health records really do have an allergy by carrying out specialist testing, and to see if it is possible to reduce the number of patients wrongly labelled as penicillin allergic. The investigators will find out if this results in better use of antibiotics and fewer days of symptoms, when patients are prescribed antibiotics for infection. * The investigators are recruiting up to 140 GP practices in Yorkshire and Humber and the South West Peninsula to help with this research, and plans to include up to 1060 people.
Interventions
PROCEDUREpenicillin allergy assessment pathway
Summary of penicillin allergy assessment pathway : Stage-1 PAAP in Primary Care - Clinical History. Screening, questionnaire and antimicrobial history will be undertaken in primary care Stage-2 Skin Test(ST) in hospital clinic (this may not be needed for all participants) Stage 3 Oral Challenge Test (OCT) in hospital clinic Testing will involve half a day in clinic and then a three-day post clinic course of oral antimicrobial therapy, without a reaction
Sponsors
University of Oxford
University of Leeds
Study design
Allocation
RANDOMIZED
Intervention model
PARALLEL
Primary purpose
SCREENING
Masking
NONE
Intervention model description
Multicentre, two parallel-arm, open label, individually randomised pragmatic trial with a nested-pilot study
Eligibility
Sex/Gender
ALL
Age
18 Years to No maximum
Healthy volunteers
Yes
Inclusion criteria
* Participant is willing and able to give informed consent for participation in the study * Male or Female, aged 18 years or above * Current penicillin allergy (or sensitivity) record of any kind in their electronic health record * Receipt of either: penicillin, cephalosporin, tetracycline, quinolone or macrolide class antibiotic or fosfomycin, nitrofurantoin, trimethoprim, clindamycin in the previous 12 months N.B.1 Patients who have been formally tested for penicillin allergy in the past and been found not to be penicillin allergic but still have a medical record indicating a penicillin allergy, are eligible for the trial.
Exclusion criteria
* Life expectancy estimated \<1 year by GP * Unable to attend immunology clinic * Unsuitable for entry into testing pathway because: * Allergy history consistent with anaphylaxis to penicillin * History of toxic epidermal necrolysis, Stevens-Johnson syndrome, Drug reaction with eosinophilia and systemic symptoms (DRESS) or any severe rash which blistered or needed hospital treatment, and acute generalised exanthematous pustulosis precipitated by a penicillin * Has been formally tested for penicillin allergy in the past and been found to be penicillin allergic * History of brittle/severe asthma or has had a course of steroids in the past 3 months for asthma or unstable coronary artery disease, or dermographism or other severe/poorly controlled skin conditions * Considered unsuitable for trial participation by the GP e.g. because of chaotic lifestyle * Pregnant * Breastfeeding mothers * Taking beta blocker medication, and unable to temporarily withhold these on the day of penicillin allergy testing * Currently taking (or recently taken) systemic steroids and unable to stop these for 10 days pretesting. * Currently taking antihistamines and unable to temporarily withhold these for 72 hours pre-testing GPs may also want to exclude vulnerable patients who are deemed to be unsuitable to participate for other reasons such as, but not limited to, terminal illness, reliability, mental illness, learning difficulties, anxiety, and other family circumstances. N.B.1 Patients that are currently taking medicines with antihistamine properties that cannot be temporarily withheld, or patients with isolated dermographism, may still be eligible to participate but will need to be discussed with the research team prior to consent. N.B.2 Pregnancy and breastfeeding
Design outcomes
Primary
| Measure | Time frame | Description |
|---|---|---|
| Penicillin prescribing | Measured at up to 12 month post-randomisation | The proportion of participants who receive prescriptions for a penicillin when attending for predefined conditions where a penicillin is the first-line recommended antibiotic |
Secondary
| Measure | Time frame | Description |
|---|---|---|
| Meticillin-resistant Staphylococcus aureus (MRSA) infection/ colonisation | Measured up to 12 month post-randomisation | Total number of patients with MRSA infection/colonisation compared between intervention arms |
| Treatment response failure | Measured after first antibiotic prescription, which can occur any time during the follow-up period for patients(Up to 12 months post randomisation) | Treatment response failure will be defined as: Re-presentation with worsening or non-resolving symptoms following treatment with an antibiotic up to 28 days after initial antibiotic prescription (including re-prescription of antibiotic within 28 days of an index prescription) for predefined conditions (TPP/notes review), over the year subsequent to randomisation. This will be compared between groups |
| Symptom duration | Measured up to 12 month post-randomisation | Duration of symptoms (in days) rated 'moderately bad' or worse by patients, after initiation of antibiotic treatment |
| Total antibiotic prescribing | Measured up to 12 month post-randomisation | Count of total antibiotic use (measured as total number of days therapy and as average daily quantity (ADQ) antibiotics. Total number of penicillin and each non-penicillin antibiotic prescriptions (measured as total number of days therapy and ADQ) |
| Hospital admissions | Measured up to 12 month post-randomisation | Count of total number of hospital admissions |
| Length of hospital stays | Measured up to 12 month post-randomisation | Count of total length of hospital stays |
| Mortality rates | Measured up to 12 month post-randomisation | Mortality rates compared between intervention arms |
| Cost effectiveness for the PAAP intervention compared to usual care | Collated for period: randomisation to up to 12 months of randomisation | Measurement of quality adjusted life years in each arm |
| De-labelling | check performed at 3 and 12 months | The proportion of ALABAMA participants whose labels were removed and remain removed from the medical eHR |
| Clostridium difficile infection | Measured up to 12 month post-randomisation | Number of patients with Clostridium difficile infection |
| (Process evaluation) To explore patient and clinician experiences of trial procedures. | Within 12 months of practice recruitment of a proportion of tested patients | GP and patient interviews |
| To measure changes in clinician and patient behaviour change regarding prescribing and consuming penicillin following a negative test result. | Within 12 months of practice recruitment of a proportion of tested patients | Change in self-reported behaviour by clinicians and patients. |
| To measure the influences on clinician and patient behaviour change regarding prescribing and consuming penicillin following a negative test result. | Within 12 months of practice recruitment of a proportion of tested patients | influences on behaviour by clinicians and patients. |
Other
| Measure | Time frame | Description |
|---|---|---|
| AEs and SAEs reported | Measured at up to 12 month post-randomisation | A descriptive analysis will be performed looking at the safety (number of AEs and SAEs) of de-labelling in the intervention group |
| Effects of PAAP on all outcomes for follow up past 12 months | Measured at the end of the study | Descriptive analysis using data captured in the notes review CRF |
Countries
United Kingdom
Outcome results
None listed