Antibiotics - penicillin allergy de-labelling

Background (age, sex, occupation, baseline function)

• 85-year-old female, retired office worker who lives alone
• Usually manages at home with support from family for meals, shopping and housework

History of presentation/reason for review

• Admitted to hospital after being found by family member on the bathroom floor having fallen overnight
• Spiking temperatures, complaining of back pain, dysuria, urinary frequency and new urinary incontinence. Has signs and symptoms of heart failure including increasing shortness of breath and ankle swelling
• Family say she is more confused than usual, resisting help to get into the ambulance, resisting offers of food and fluid
• Single dose of gentamicin given empirically on the day of admission for a working diagnosis of upper urinary tract infection
  • After receiving the dose, she removed the intravenous cannula and resisted attempts to re-site the cannula, therefore oral treatment considered
• MSU result showed multiple antibiotic resistance with sensitivity to amoxicillin and so treatment with oral penicillin was considered.
• The nature of penicillin allergy was discussed with the individual and her family. According to GP records and next of kin penicillin “allergy” was nausea and diarrhoea more than 20 years ago during a course of amoxicillin for a chest infection. No reported rash or need for hospitalisation. At the time, she finished the course, and the GP documented the allergy

Current medical history and relevant co-morbidities

• Heart failure with preserved ejection fraction (ECHO within the last year)
• Mild Alzheimer’s dementia (MMSE 23/30) – 4 years ago
• COPD – 12 years ago
• Generalised osteoarthritis – 27 years ago

Current medication and drug allergies (include over the counter (OTC) preparation, traditional medicines and herbal remedies)

Allergies: Penicillin

Current medications:

• Atorvastatin 80mg tablets: one tablet in the morning
• Donepezil 5mg tablets: one tablet in the morning
• Furosemide 20mg tablets: one tablet in the morning
• Lisinopril 5mg tablets: one tablet in the morning
• Macrogol 3350 sachets: one sachet twice daily
• Paracetamol 500mg caplets: two caplets four times daily
• Salbutamol 200 microgram dry powder inhaler: one inhalation when required for shortness of breath/ wheeze
• Senna 7.5mg tablets: two tablets at night
• Trelegy Ellipta® (fluticasone 92 micrograms/ vilanterol 22 micrograms/ umeclidinium 65 micrograms) dry powder inhaler, one inhalation in the morning

Over the counter medicines: nil

Lifestyle and current function

• The family feel that medication is not being taken regularly, boxes of tablets and inhalers are often found around the house
• Ex-smoker, 10 pack years, stopped 20 years ago
• Alcohol occasionally at celebratory events
• Walks for about a mile most days with a friend or family member
• Clinical Frailty Score (Rockwood) 5 (living with mild frailty)

“What matters to me” (ideas, concerns and expectations of treatment)

• She has always expressed a wish to maintain independence as long as possible. Currently has delirium
• Family wish to support her at home for as long as possible with a focus for medication on symptom relief

Observations, examinations and results 

Note: local laboratory reference ranges may vary

• Weight 47kg, Height 158cm, BMI 18kg/m²
• BP 108/56 mmHg, pulse 68bpm regular, oxygen saturation 96% on air, respiration rate normal
• Noted to have reduced mobility and marked pitting oedema to both knees
• Urea and Electrolytes
  • Potassium 5.2mmol/L (3.5-5.3mmol/L)
  • Sodium 138mmol/L (133-146mmol/L)
  • Urea 8.6mmol/L (2.5-7.8mmol/L)
• Creatinine 110micromol/L (60-120micromol/L), Calculated creatinine clearance 25 mL/min
• WBC 9x10⁹/L (4.0-10.0x10⁹/L).
• CRP 72mg/L (0-10mg/L)
• ECG: sinus rhythm, heart rate 72bpm
• Urine culture: sample sent by GP and results available the day after admission
  • Organism: Escherichia coli
  • Organism Growth 105 orgs/ml
  • Sensitive to amoxicillin, gentamicin, aztreonam
  • Resistant to trimethoprim, ciprofloxacin

Most recent relevant consultations

• Recent dietetic advice provided regarding high nutrient density food to encourage weight gain and family have been incorporating that into meals
• Whilst in hospital:
  • Lisinopril withheld on admission due to low blood pressure
  • Atorvastatin withheld on admission due to lack of indication
  • Furosemide continued due to oedema and increased shortness of breath
• Furosemide continued due to oedema and increased shortness of breath

Person specific issues to address

• She wishes to maintain independence as long as possible and return home as soon as able
• Focus is on symptom relief - breathlessness, pain from osteoarthritis and maintaining cognition

 

Person specific issues to address

• As she has a UTI and delirium, antibiotic treatment is essential
• Donepezil can delay progression to 24-hour care (priority for her)

 

Person specific issues to address

• Review the continued need for IV antibiotics
• Lisinopril of limited benefit as preserved ejection fraction so stop
• She has had fewer than two exacerbations of COPD in the last year and no raised blood eosinophils - step down to LAMA/ LABA inhaler (Anoro Ellipta®)
• Discuss need for laxatives: could be used when required

 

Person specific issues to address

• Judged to be very low probability of immediate penicillin hypersensitivity reaction, and so after discussion with her and next of kin, proceeded to amoxicillin oral challenge
• Given single dose of oral amoxicillin and monitored at 10, 20, 40 and 60 minutes. Experienced no symptoms of nausea, no rash or lip/tongue tingling or swelling, no tachycardia or hypotension
• Proceeded to a course of amoxicillin for seven days for a suspected upper UTI. Antibiotics were completed without any adverse effect
• Monitor breathlessness (also review inhalers)

 

Person specific issues to address

• Medication Sick Day Guidance for furosemide and lisinopril
• Donepezil caution in COPD but control is good
• Paracetamol dose in individual weighing less than 50kg: reduce dose and consider adding ibuprofen gel for painful joints

 

Person specific issues to address

• Consider use of oral rather than IV antibiotic (e.g. individual acceptability and sustainability)  
• After assessment by a pharmacy technician, she is struggling to use dry powder devices. She cannot “feel” the dose being taken and therefore orders more inhalers every month, presuming that it is empty. After discussion about how the dry powder device works, she felt more confident she was receiving the required dose.
• Advised to dispose of medicines through the community pharmacy
• Advised to only order what is needed, do not stockpile medicines  

 

Agreed plan

• On discharge the GP was informed that the penicillin allergy was de-labelled and her GP records were updated and discussed with family so that they were aware for future episodes
• Stop Clear note on discharge to GP about reason for this
• Reduce paracetamol dose to 500mg up to four times a day
• Change Trelegy® to Anoro Ellipta® device
• Referred to the GP practice pharmacy technician to assess ways of supporting medicines management at home and remove unnecessary medicines
• Ensure a written copy of the plan made for future reference by individual, family and carers