How primary care can improve antimicrobial stewardship

December 9, 2022

Antimicrobial resistance — when pathogens develop resistance to drugs used to fight them — is a serious threat to health care in New Zealand and around the world. Antimicrobial stewardship — ie careful and appropriate use of antimicrobial drugs (including antibiotics) — is vital to preserving the effectiveness of these medicines.

This article explains the key role of primary care in antimicrobial stewardship. There is a clear role for prescribers, but nonprescribers such as primary health care nurses also have an important part to play in supporting the appropriate use of antimicrobials.

PHOTO: ADOBE STOCK

Antimicrobial drugs — including antibiotics, antivirals, antifungals and antiparasitics — are used to fight pathogens in humans, and also in animals, plants and the environment.

However, any use of antimicrobial medicines produces selection pressure, where the most susceptible microbes are killed, promoting the surviving microbes to flourish and pass their resistant features to new generations. This antimicrobial resistance is accelerated by inappropriate use of antimicrobials and inadequate infection prevention and control.1

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Antimicrobial resistance (AMR) presents an imminent threat to the future of New Zealanders’ wellbeing and access to effective, safe health care. This was comprehensively laid out in a December 2021 report from the prime minister’s chief science advisor, Juliet Gerrard.2

The report’s expert panel makes recommendations that have their roots in the 2017 New Zealand National AMR Action Plan as well as in the local and international evidence.1 In the words of Dame Juliet, “The time for action is now.”2

Use of antimicrobials in human health is high in Aotearoa New Zealand compared with many other countries.2,3 In recent years, there have been encouragingly positive trends that show our antimicrobial use does not need to be so high. During COVID-19 lockdown in 2020, it decreased by a significant 36 per cent with no evidence of harm4 (much of this reduction would be due to less use of antibiotics for viral respiratory tract infections in general).

KEY POINTS

  • Antimicrobial stewardship (AMS) is about optimally managing infections and minimising antimicrobial-related harms, including antimicrobial resistance (AMR), toxicity and cost.
  • Good AMS practice includes putting a meaningful indication for antimicrobial use on prescriptions, ie stating what specific condition the drug is for.
  • Incorrectly labelling patients as having a penicillin allergy can cause harm as this often leads to them being prescribed second-line antibiotics that are less effective, broader spectrum and/or more toxic than penicillins.
  • There is a push for national leadership and coordinated efforts to improve AMS.

Before that, a modest 14 per cent decrease in use was recorded across 2015 to 2018 (an average reduction of 3.5 per cent per year), mainly due to reductions in antimicrobial use in under five-year-olds.5

The reduction between 2015 and 2018 may reflect changing attitudes due to sustained efforts, led by clinicians, to discourage inappropriate antimicrobial use.6 Through our collective experience with COVID-19, it is hoped there is now greater public awareness that antibiotics do not help viral illnesses.

The task is to build on these gains, particularly in primary health care. What limited resources there are to support appropriate antimicrobial use focus on public hospitals rather than community health care.6 Ironically, 95 per cent of our antimicrobial use is in the community7 and up to half of this may be inappropriate.8

The purpose of this article is to provide an overview of the ongoing high-level initiatives for improving antimicrobial stewardship and the New Zealand antimicrobial prescribing landscape as it stands. It also outlines actions that can immediately improve in primary health care:

  • ensuring good antimicrobial handling and prescribing practice, including the addition of a meaningful indication on every antimicrobial prescription
  • addressing penicillin allergy.
Initiatives and leadership in Aotearoa New Zealand

 The Government, health-care system and population of New Zealand have received international praise for their collective response to the COVID-19 pandemic. It is urgent that an equally commendable strategy be implemented to counter the gradually developing – but also likely as catastrophic – pandemic of antimicrobial resistance.

“AMR is the developed resistance of a microorganism (bacterium, virus, fungus or parasite) to an antimicrobial agent that it was originally susceptible to. AMR occurs naturally, but is facilitated by antimicrobial use, and inadequate infection prevention and control.” 6

 The core required strategy of antimicrobial stewardship is an established concept, which has been implemented with greater success in many other countries, including Australia.

“AMS aims to optimise the use of antimicrobial agents in the prevention and treatment of infections, and minimise the potential harms that may result from their use including AMR, adverse drug reactions and excessive health-care costs. An AMS programme includes governance, surveillance of the quantity and quality of antimicrobial use, education and training, and implementation of quality improvement initiatives.”6

What nurses can do

Nurse prescribers have a clear role in ensuring good antimicrobial stewardship. Non-prescribing nurses in primary care can also support the appropriate use of antimicrobials by:

  • communicating with patients and prescribers
  • explaining to patients that antibiotics are not useful for viral infections
  • understanding that they shouldn’t be used “just in case”
  • reviewing patients’ penicillin “allergy”
  • encouraging documentation of indication on the script and ensuring short courses where appropriate.

In New Zealand, the development of an AMS strategy to be implemented across the health sector has been slow, siloed, often conflicting and, in areas of primary care, lacking. The new Ngā Paerewa Health and Disability Services Standard sets minimum AMS requirements that some service providers (eg residential care and public hospitals) must meet to be certified under the Health and Disability Services (Safety) Act 2001.9

Not all primary care is included in this standard, but this could be rectified by developing a separate clinical care standard for antimicrobial stewardship that applies to all who prescribe, dispense or administer antimicrobials.6

AMS and infection prevention and control (IPC) are two human-health components within a wider New Zealand AMR action plan. This plan sets out a One Health approach to addressing AMR that acknowledges relationships between human health, animal health, agriculture and the environment.2

Nearing the end of this five-year action plan, progress in human health has been poor.6 Despite the science and solutions being clear (New Zealand is a member of the Global Health Assembly and is aligned with The Tripartite Global Action Plan on Antimicrobial Resistance 2015),10 implementation has fallen short. Almost none of the recommendations in the 2017 action plan have been put into place, even though the “bar was set low” to see what could be achieved without additional investment.2

Opinion leaders –  including Te Whatu Ora Health New Zealand AMS pharmacists, infectious disease physicians, clinical microbiologists, IPC nursing specialists and other experts – continue to push for national leadership and coordinated efforts on AMS, most recently in a 2021 New Zealand Medical Journal viewpoint.6

A key stakeholder group, the New Zealand Antimicrobial Stewardship and Infection Pharmacist Expert Group (NAMSIPEG), has also led promotion of good AMS practices and activities for World Antimicrobial Awareness Week (WAAW).11 For 2020, it led a national initiative to improve indication documentation on antimicrobial prescriptions, and for 2021 a national initiative focusing on penicillin allergy.12,13,14 These are component parts to AMS and are applicable in primary care.

For WAAW 2022 (November 18-24), NAMSIPEG promoted best practice for the disposal of antimicrobials.

Prescribing landscape for antimicrobials in Aotearoa New Zealand

The implications of AMR for New Zealanders and the imminent threat it represents have been made plain by the Royal Society Te Apārangi in 201715 and the Office of the Prime Minister’s Chief Science Advisor in 2021.2

Estimates suggest, without urgent action, infections due to resistant microorganisms could kill 10 million people globally each year by 2050.16 Using a predictive model, a systematic analysis published this year in The Lancet has already estimated that approximately 6.3 million deaths globally in 2019 were attributable to, or associated with, bacterial AMR.17

The consequences of increases in AMR for New Zealand will be enormous, given the reliance we have on effective antimicrobial therapy throughout medicine. What is certain is that AMR will disproportionately impact the most socioeconomically disadvantaged New Zealanders.2

Rates of some infections, including sepsis, in Māori and Pacific peoples are about twice those in people of European descent and other ethnic groups, and rates are significantly above average in the youngest, oldest and most deprived population groups.18

One of the biggest drivers for AMR is antimicrobial use. Antimicrobial use in New Zealand human populations is high compared with many developed countries.7,19 New Zealand has:

  • the fourth highest level of antibiotic prescribing (measured in defined daily dose per 1000 people) in 2017, surpassed only by Greece, Italy, and Korea2,3
  • a community antibacterial consumption rate that increased 49 per cent between 2006 and 201419
  • near-universal (97 per cent) antibiotic exposure by school age20
  • 95 per cent of human antibiotic use in the community.7

Small positive trends can be found. Over three years (2015 to 2018), community antibiotic use reduced by 14 per cent, mainly due to reductions in children under five years old.5 And during the 2020 lockdown, antimicrobial use decreased considerably, by 36 per cent, without evidence of harm.4 Thus, much of the previous “usual” antibiotic use may have been for viral respiratory tract infections, and unnecessary.

Antimicrobials are the only class of medicine where the treatment decisions made for an individual have broader ramifications for their whānau and the wider community.

 The consequence of antimicrobial use is that it produces selection pressure on the microbial environment and promotes a proliferation of resistant strains with the potential for harm.1 Some bacteria have become multi-resistant, ie they are resistant to more than one antibiotic. These include methicillin-resistant Staphylococcus aureus (MRSA) and ciprofloxacin-resistant Neisseria gonorrhoeae which already challenge clinical care in this country.

However, the steadily increasing incidence of infections caused by multi-resistant Enterobacterales, such as Escherichia coli and Klebsiella pneumoniae, in hospitalised and community patients, is of greatest concern.20,21,22

  • Extended spectrum β-lactamase-producing Enterobacterales (ESBL-E) are resistant to most penicillins and cephalosporins, and often also to other unrelated agents like trimethoprim and ciprofloxacin.
  • Carbapenemase-producing Enterobacterales (CPE) are resistant to almost all antimicrobial agents, including “ultra-broad-spectrum” carbapenems (a sub family of β-lactams mainly used in hospitals), and have 30 to 50 per cent mortality when they cause invasive infections.23 The Institute of Environmental Science and Research (ESR) recorded a greater than 10-fold increase in identified CPE isolates during 2010–2019.22

At the patient–clinician level, the impact of an infection due to a multi-resistant pathogen means:

  • reduced, and in some cases no, effective funded oral antimicrobials (this is increasingly seen with cystitis due to ESBL-E in the community)
  • reduced efficacy when using second-line antimicrobials
  • higher toxicity and rates of adverse effects from the use of second-line agents
  • increased costs and inconvenience for patients who need hospital visits for antimicrobial therapy (affecting rural/low socioeconomic groups disproportionately)
  • longer hospital stays
  • poorer outcomes from surgery (eg, joint replacement), cancer care and other interventions
  • increased mortality
  • elevated health-care costs.6

In addition to the selection pressure for AMR caused by antimicrobial use, adverse drug events (ADE) are also common when antimicrobials are used. A 2017 study found 20 per cent of hospitalised patients in the United States receiving at least 24 hours of antibiotic therapy developed an antibiotic-associated ADE. Moreover, 20 per cent of ADEs were attributable to antibiotics prescribed for conditions for which antibiotics were not indicated.24

Use of antimicrobial drugs kills susceptible organisms (those in blue in the diagram) but leaves resistant organisms (in orange) free to proliferate. GRAPHIC: ADOBE STOCK

The overarching goal of AMS is wider than counteracting AMR alone – it is to improve patient outcomes as well. Prescribing a first-line antibiotic choice, where one is indicated and appropriate, helps to improve patient outcomes, partly by reducing the risk of ADEs.

Non-β-lactam antibiotics are commonly used as second-choice agents, but they carry a raised ADE risk, eg, hyperkalaemia with trimethoprim + sulfamethoxazole. Adverse effects with quinolone antibiotic use are numerous and they have led to US Food and Drug Administration25 and European Medicines Agency26 warnings regarding their use. First-line antibiotic prescribing helps to avoid this risk.

Patient outcome is also impacted by the effect of antibiotic use on the microbiome, which can result in greater risk for infection associated with Clostridioides difficile (formerly named Clostridium difficile) or candida.

Antimicrobials are the only class of medicine where the treatment decisions made for an individual have broader ramifications for their whānau and the wider community. This means that decisions about treating infections affect the outcomes for patients in general, not just the one sitting in front of you.

 Good prescribing practice and defined indications

Antimicrobial stewardship involves coordinated strategies designed to measure and support appropriate antimicrobial use. The overarching aims are to improve patient outcomes by managing infections optimally while minimising antimicrobial-related harms, including AMR, toxicity and cost.

Among the strategies for AMS lies a central principle – one that can be applied as well by all prescribers in primary health care as it can in the hospital setting. That is, understanding the indication for antimicrobial use underpins all assessments of the quality (appropriateness) of antimicrobial prescribing, including guidelines compliance.

Inclusion of a meaningful indication for antimicrobial use on the prescription is a key quality indicator for AMS as it promotes good practice and outcomes (see panel). There is no nationally set target for this indicator, but NAMSIPEG recommends aiming for ≥95 per cent of prescriptions being annotated with a meaningful indication (this aligns with the equivalent quality indicator used in Australia).13

The importance of a meaningful indication

Prescriptions for antimicrobials should include a meaningful indication — ie, they should clearly specify what condition the drug is intended to treat. This will:

  • promote thoughtful antimicrobial prescribing
  • facilitate communication between health-care providers, and with patients
  • support timely reassessment of the ongoing appropriateness of antimicrobial use
  • provide justification for non-guideline-compliant prescribing
  • reduce patient harm from inappropriate antimicrobial use and errors from prescription misinterpretation
  • assist quality improvement initiatives and auditing.

A meaningful indication for antimicrobial use on the prescription means being specific. For a urinary tract infection for example, rather than using a very general term like “for infection”, examples of meaningful terms include “cystitis”, “lower UTI” or “pyelonephritis”.

The following further considerations can help make sure both the antimicrobial and the patient are “handled with care”:

  • Only use the antimicrobial if the benefits outweigh the harms – never “just in case” or to alleviate “worry”.
  • If the antimicrobial is warranted, use it optimally – the “right” agent, dose, route and duration.
  • Use the prescription to justify antimicrobial use – document a meaningful indication (see panel above).
  • Determine and document the treatment duration or a review date – most courses should be short and sharp (check local guidelines and engage with specialty services if needed).
  • If the patient has a documented “penicillin allergy”, consider a review of how this was determined (see the following section on penicillin allergy to decide whether a challenge to its veracity is appropriate).
De-labelling penicillin allergy

Penicillins are a group of antibiotics that are often a first-choice treatment for infection because they tend to be more effective and cause fewer problems such as side effects.

Nevertheless, penicillin allergy is the most common adverse drug reaction to be reported. However, our understanding of this has evolved in recent years.

While approximately 10 per cent of adults believe they are allergic to penicillin, about 90 per cent of these people do not have a true immune-mediated allergy. Reactions such as nausea, diarrhoea or thrush often occur with antibiotics but are side effects, not allergies.

If the patient has a documented ‘penicillin allergy’, consider a review of how this was determined.

 A further point to consider is that antibiotic allergies will often resolve over time – approximately 50 per cent of skin-prick test-positive penicillin allergies are lost over five years, and about 85 per cent over 10 years.14 Consequently, a reaction to penicillin during a childhood infection is unlikely to be a true allergy in adulthood.

A childhood reaction to penicillin may often be outgrown in adulthood. GRAPHIC: ADOBE STOCK

However, with any history of presumed immune-mediated reaction (eg, a delayed non-severe reaction or mild rash), an oral rechallenge with low-dose penicillin (usually amoxicillin) can be used to confirm safety before prescribing a therapeutic course. This is usually done in hospital.27

Incorrect “penicillin allergy” labels on patients’ records cause harm as they often lead to the use of second-line antibiotics that are less effective, broader spectrum and/or more toxic.14

Having a penicillin allergy label has been associated with:

  • an increased risk of Clostridioides difficile, methicillin-resistant Staphylococcus aureus (MRSA), and vancomycin-resistant enterococci infections and colonisation
  • increased use of broad-spectrum antibiotics, contributing to AMR
  • lengthier hospital stays
  • higher hospital readmission rates
  • surgical site infections
  • admissions to intensive care units.27

A study of 2.3 million general practice adult patients in the United Kingdom found penicillin allergy labels are associated with a significantly increased risk of death in the following year (relative risk 1.08), re-prescription of a new antibiotic class within 28 days (RR 1.32), and MRSA infection or colonisation (RR 1.90), when compared with patients with no penicillin allergy label.27

Based on the numbers, most patient penicillin-allergy labels can be removed, but the heart of the matter for primary health care is — which ones can be safely removed with a patient interview and notes review alone?

Only use an antimicrobial if the benefits outweigh the harms – never ‘just in case’ or to alleviate ‘worry’.

Formal referral pathways for oral challenges are not yet established for primary care. Thus, a focus on patients in the “negligible risk” category is needed; they may be de-labelled following an interview and notes review alone (with no need for oral amoxicillin challenge or engagement with specialty services). Check, however, for local policies or guidelines. 

The medical records for patients at “negligible risk” for removing the penicillin allergy label will reflect the penicillin having caused one or more of the following:

  • expected gastrointestinal side effects (eg, nausea, vomiting, diarrhoea)
  • thrush (any kind)
  • mild, reversible kidney, liver or neurological dysfunction
  • allergy reported but the same antibiotic tolerated subsequently
  • family history of penicillin allergy only.

Reading this article and reflecting on its content can equate to one hour of CPD time. Nurses can use the Nursing Council’s professional development activities template to record professional development completed via Kaitiaki, and they can then have this verified by their employer, manager or nurse educator.

Patients can be reminded why penicillins are useful and effective — this and many other helpful patient messages can be found in a resource produced by NAMSIPEG.28

Where a true immune-mediated penicillin allergy is reasonably considered to exist, this does not mean other β-lactam antibiotics cannot be used – sometimes, they can be. Cross-reactivity is less than 2 per cent with cephalosporins and less than 1 per cent with carbapenems but this varies with chemical structure. Advice from infectious diseases and/orimmunology specialists should be sought.

It is also worth noting that the blood-testing laboratory can sometimes offer additional antibiotic choices for a patient with severe penicillin allergy as they may notrelease all susceptibility results initially. NPS Medicinewise provides a practical approach to assessment and prescribing with penicillin allergy.29

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This article was reviewed for He Ako Hiringa  by Sharon Gardiner, BPharm(Hons), MClinPharm, PhD, who is the antimicrobial stewardship pharmacist at Te Whatu Ora Waitaha Canterbury and co-leadof the New Zealand Antimicrobial Stewardship and Infection Pharmacist Expert Group (NAMSIPEG).

References

  1. Ministry of Health and Ministry for Primary Industries. (2017). New Zealand Antimicrobial Resistance Action Plan.
  2. Office of the Prime Minister’s Chief Science Advisor. (2021). Uniting Aotearoa against infectious disease and antimicrobial resistance.  A report from the Prime Minister’s Chief Science Advisor, Kaitohutohu Mātanga Pūtaiao Matua ki te Pirimia.
  3. OECD. (2019). Health at a Glance 2019.
  4. Duffy, E., Thomas, M., Hills, T., & Ritchie, S. (2021). The impacts of New Zealand’s COVID-19 epidemic response on community antibiotic use and hospitalisation for pneumonia, peritonsillar abscess and rheumatic fever.  The Lancet Regional Health – Western Pacific, 12, 100162.
  5. Thomas, M., Tomlin, A., Duffy, E., & Tilyard, M. (2020). Reduced community antibiotic dispensing in New Zealand during 2015-2018: marked variation in relation to primary health organisation. New Zealand Medical Journal, 133(1518), 33-42.
  6. Gardiner, S. J., Duffy, E. J., Chambers, S. T., Thomas, M. G., Addidle, M., Arnold, B.,
    Arroll, B., Balm, M., Perales, C. B., Berger, S., Best, E., Betty, B., Birch, M., Blackmore, T. K., Bloomfield, M., Briggs, S., BuphaIntr, O., Burns, A., Campbell, C., Chin, P. K. L., Dalton, S. C., Davies, N., Douglas, N. M., du Plessis, T., Elvy, J., Everts, R., Green, J., Grimwade, K., Handy, R., Hardie, M. G., Henderson, E., Holland, D. J., Howard, J., Hudson, B., Huggan, P., Isenman, H., Issa, M., Kelly, M. J., Li, C., Lim, A. G., Lim, J., Maze, M., Metcalf, S., McCall, C., Murdoch, D., McRae, G., Nisbet, M., Pithie, A., Raymond, N., Read, K., Restrepo, D., Ritchie, S., Robertson, B., Ussher, J. E., Voss, L., Walls, T., & Yew, H. S. (2021). Antimicrobial stewardship in human healthcare in Aotearoa New Zealand: urgent call for national leadership and co-ordinated efforts to preserve antimicrobial effectiveness (viewpoint). New Zealand MedicalJournal, 134 (1544).
  7. Duffy, E., Ritchie, S., Metcalfe, S., Van Bakel, B., & Thomas, M. G. (2018). Antibacterials dispensed in the community comprise 85%-95% of total human antibacterial consumption. Journal of Clinical Pharmacy and Therapeutics, 43(1), 59-64.
  8. Thomas, M. G., Smith, A. J., & Tilyard, M. (2014). Rising antimicrobial resistance: a strong reason to reduce excessive antimicrobial consumption in New Zealand. New Zealand Medical Journal, 127(1394), 72-84.
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  11. Pharmaceutical Society of New Zealand. New Zealand Antimicrobial Stewardship and Infection Pharmacist Expert Group (NAMSIPEG) .
  12. Canterbury District Health Board, Hospital Antimicrobial Stewardship Committee. (2020). Antimicrobial Stewardship Bulletin No. 028. World Antimicrobial Awareness Week: 18-24 November 2020. Introducing a nationwide initiative to support judicious antimicrobial use via documentation of indications on antimicrobial prescriptions November 2020.
  13. Canterbury District Health Board, Hospital Antimicrobial Stewardship Committee. (2021). Antimicrobial Stewardship Bulletin No. 028. World Antimicrobial Awareness Week: 18-24 November 2021. Spread Awareness, Stop Resistance. November 2021.
  14. Canterbury District Health Board, Hospital Antimicrobial Stewardship Committee. (2021). Antimicrobial Stewardship Bulletin No. 036. Penicillin allergy in adults. November 2021.
  15. Royal Society. (2017). Antimicrobial Resistance – Implications for New Zealanders, Evidence Update. Expert advice paper.
  16. O’Neill, J., for the Review on Antimicrobial Resistance. (2016). Tackling drug-resistant infections globally: final report and recommendations.  HM Government and Wellcome Trust, United Kingdom.
  17. Antimicrobial Resistance Collaborators. (2022). Global burden of bacterial
    antimicrobial resistance in 2019: a systematic analysis. The Lancet, 399(10325), 629-55.
  18. Baker, M. G., Barnard, L. T., Kvalsvig, A., Verrall, A., Zhang, J., Keall, M., Wilson, N., Wall, T., & Howden-Chapman, P. (2012). Increasing incidence of serious infectious diseases and inequalities in New Zealand: a national epidemiological study.  The Lancet, 379(9821), 1112-119.
  19. Williamson, D. A., Roos, R. F., & Verrall, A. (2016). Antibiotic consumption in New Zealand, 2006-2014.  Institute of Environmental Science and Research Ltd.
  20. Hobbs, M. R., Grant, C. C., Ritchie, S. R., Chelimo, C., Morton, S. M. B., Berry, S., Thomas, M. G. (2017). Antibiotic consumption by New Zealand children: exposure is near universal by the age of 5 years. Journal of Antimicrobial Chemotherapy, 72(6), 1832-40.
  21. Heffernan, H., Woodhouse, R., Draper, J., & Ren, X. (2018). Survey of extended-spectrum β-lactamase-producing Enterobacteriaceae. Institute of Environmental Science and Research Ltd.
  22. Institute of Environmental Science and Research Ltd. (2019). Enterobacterales with acquired carbapenemases.
  23. Xu, L., Sun, X., & Ma, X. (2017). Systematic review and meta-analysis of mortality of patients infected with carbapenem-resistant Klebsiella pneumoniae. Annals of Clinical Microbiology and Antimicrobials, 16(1), 18.
  24. Tamma, P. D, Avdic, E., Li, D. X., Dzintars, K., & Cosgrove, S. E. (2017). Association of adverse events with antibiotic use in hospitalized patients.  JAMA Internal Medicine, 177(9), 1308-15.
  25. US Food & Drug Administration. (2018). FDA Drug Safety Communication: FDA updates warnings for oral and injectable fluoroquinolone antibiotics due to disabling side effects.
  26. European Medicines Agency. (5 Oct, 2018). Fluoroquinolone and quinolone antibiotics: PRAC recommends new restrictions on use following review of disabling and potentially long-lasting side effects [press release].
  27. West, R. M., Smith, C. J., Pavitt, S. H., Butler, C. C., Howard, P., Bates, C., Savic, S., Wright, J. M., Hewison, J., & Sandoe, J. A. T. (2019). ‘Warning: allergic to penicillin’: association between penicillin allergy status in 2.3 million NHS general practice electronic health records, antibiotic prescribing and health outcomes.  Journal of Antimicrobial Chemotherapy, 74(7), 2075-82.
  28. NAMSIPEG and Pharmaceutical Society of New Zealand. (n.d.). Challenge your penicillin allergy [patient resource].
  29. Devchand, M., & Trubiano, J. A. (2019). Penicillin allergy: a practical approach to
    assessment and prescribing. Australian Prescriber, 42, 192-9.