Removal of EHR Warning Linked to Increase in Cephalosporin Use in Patients With Penicillin Allergy

After removal of the warning, cephalosporin use increased from 17.9% to 27.0% at the intervention site.

Removal of the default warning in the electronic health record (EHR) urging the avoidance of cephalosporins in patients with penicillin allergy led to an increase in prescribing of these agents and a decrease in use of second-line antibiotics, according to the findings of a cohort study recently published in JAMA Network Open.

To assess whether removing the warning urging avoidance of cephalosporins in patients with penicillin allergy would be associated with changes in either the dispensing or administration of these agents, study authors analyzed data from 2 health system sites (1 designated as an intervention site that removed the warning and another that retained the warning) between January 1, 2017 and December 31, 2018. A total of 4,206,480 patients met eligibility criteria and were included in the analysis.

“A multinomial logistic regression model was used to examine the change in rates of cephalosporin use before and after an EHR penicillin allergy alert was removed in 1 of the study regions,” the authors explained.  A total of 10,652,014 courses of antibiotics were dispensed or administered over the study period, with half of the courses occurring during the period prior to removal of the warning while the other half occurred after.

Findings of the analysis revealed that, prior to the removal of the alert at the intervention site, a total of 58,228 cephalosporin courses were administered to patients with a penicillin allergy, which accounted for 17.9% of the site’s antibiotic use. After removal of the warning, cephalosporin use increased to 27.0% at the intervention site. At the comparison site, which retained the warning, cephalosporin use increased from 15.3% to 16.2%. “This translated to a statistically significant increase in cephalosporin use at the intervention site (ratio of ratios of odds ratios [RROR], 1.47; 95% CI, 1.38-1.56) during the period after removal of the penicillin allergy warning,” the authors reported.

At the treatment-course level, no significant differences were observed in anaphylaxis, new allergies, or treatment failures. Moreover, no significant differences were seen in all-cause mortality, hospital days, and new infections when analyzed at the patient level.

“This simple and rapidly implementable system-level intervention may be useful for improvement in antibiotic stewardship,” the authors concluded.

Disclosure: One study author declared affiliations with biotech, pharmaceutical, and/or device companies. Please see the original reference for a full list of authors’ disclosures.


Macy E, McCormick TA, Adams JL, et al. Association between removal of a warning against cephalosporin use in patients with penicillin allergy and antibiotic prescribing. [published online April 29, 2021]. JAMA Network Open. doi: 10.1001/jamanetworkopen.2021.8367

This article originally appeared on MPR