Penicillin Allergy (Patel, 9/23/26)

A recording of this presentation is available HERE.

Thank you to our Pharmacy Supervisor, Omi Patel, PharmD, for a super interesting presentation this week on Penicillin Allergy. Please do watch the presentation if you have a chance! If not, my notes:

The label penicillin (PCN) allergy is WIDELY used on patient charts. And more often than not, is untrue. Look at the numbers:

And this label, is NOT harmless!

• it can lead to the use of less effective therapies (e.g. cephalosporins are much more effective against MSSA than vancomycin)
• it can lead to more antibiotic resistance and increased risk for c. diff infection
• it can prolong length of stay in the hospital and increase hospital costs (more expensive and less effective abx)
• is can cause paradoxically MORE toxicity (e.g. a septic PCN-allergic patient will get more powerful, less effective, and more problematic drug combinations)

To review, PCN drug reactions fall into four main categories, labeled Type 1( IgE and mast cell mediated), II (cytotoxic and IgG and IgM mediated), III (immune complex, IgG and IgM and complement) and IV (T-cell mediated delayed reactions, which can be benign or severe).

Of note, Type IV (delayed rash) can be everything from totally benign to life threatening (SJS, DRESS). This is important because a patient with Type IVb rash can still be a candidate for re-labeling, whereas a patient with life-thretening Type IVd rash should never receive PCN again!

Immediate/IgE reactions generally occur very quickly, often within the first 1 hour (and almost always within the first 6 hours) of exposure. Also urticaria/hives that lasts longer than a day is generally not life-threatening. An hives reaction that occurs within 1 hour of the 1st dose, lasting less than 1 day (1:1:1 rule) is more likely to be a TRUE IgE allergy.

Patients with a history suggestive of SJS, DRESS, AIN, recent anaphylaxis and/or angioedema should not receive PCN again. Patients with intolerance (n/v/headache) a delayed benign rash (maculopapular, no organ involvement), family history only ("I was told as a child"), or a remote untreated mild reaction (>5-10 years ago) should be considered for a challenge or retesting.

I like these 6 questions for every allergy label:

It's the R chain
Cross-reactivity between PCN allergy AND cephalosporins depend entirely on the R chain (not the shared beta lactam ring). This means that even with a proven PCN allergy, many cephalosporins can be safely used. Omi pointed us to this chart from Northwestern, a link can be found HERE. This can help clinicians and pharmacists safety select a cephalosporin for PCN allergic patients.

PEN-FAST

Omi also introduced us to the PEN-FAST score, which we will be rolling out at SSRRH in the next few months to help de-label patients with PCN allergies. The PEN-FAST score is a way to assess which patients can be safely tested with a direct amoxicillin test (rather than skin testing) as a means to de-label. (of note, regardless of PEN-FAST score, if patients has hx of SJS/TENS/DRESS, they are NEVER eligible for an amoxicillin challenge test). In patients with a PEN-FAST score of 1-2, direct oral challenge (with amoxicillin) is safe and effective.

Patients with a score of 3 need a graded challenge

Patients with a score of 4-5 should NOT be tested with an oral challenge or graded challenge

In a graded challenge, you start with super low dose and see if there is a reaction (if there is, you confirm the label and stop). In a desensitization protocol, patients are treated THROUGH their reaction. 

Of note, in a study done at a Sutter hospital, they found that MOST PCN allergic (37/41) patients are not truly allergic and could tolerated an oral test dose of amoxillin, which then allowed us to de-label them! Some did have mild reactions (e.g. maculopapular rash), but this does not mean they have a true life-threatening PCN allergy. 

PMOS (PCOS): Not Just Irregular Periods (Bongato, 9/16/26)

A recording of this presentation is available HERE.

***

Thanks to Dr. Charlene Bongato for an excellent update on Polyendocrine Metabolic Ovarian Syndrome (PMOS), formerly known as Polycstic Ovarian Syndrome (PCOS). It was recently renamed to capture the reality that the disease, as we now understand it, is not a primary ovarian problem but rather a multifactorial syndrome with environmental influences and characterized by: 

1) hyperandrogenism 

2) ovulatory dysfunction 

3) polycystic ovarian morphologic features

***it is important to note that while insulin resistance is closely associated, it is NOT a defining feature

5-13% of female patients meet criteria for PMOS (by Rotterdam criteria, see below)

it is the most common cause of anovulatory fertility

~70% of patients remain undiagnosed

PMOS is caused by dysregulated ovarian androgen excretion or increased extra ovarian androgen production, characterized by excess LH and decreased FSH.

"Atypical PMOS" is obesity-related

Rotterdam criteria (must meet at least 2/3)

• oligo- or an- ovulation
• clinical or biochemical signs of hyperandrogenism
• polycystic ovaries by ultrasound

Additionally, per ACOG, Anti-Mullerian hormone (AMH) can serve as a diagnostic marker of PMOS when factors such as age, phenotype, BMI, etc are taken into account. 

How to assess for excess androgen?

1) Clinical assessment for hirsutism, using the modified Ferrimen Gallwey Score

additional manifestations of hyperandrogenism include acne (2.8x more prevalent in adolescents with PMOS), androgenic alopecia, seborrhea, hyperhidrosis, hydranitis suppurativa

***note: virilization is abnormal in PMOS and should prompt investigation for other causes of hyperandrogenism

2) Laboratory assessment: total and free testosterone (can consider DHEA, androstenedione if testosterone is normal)

Take care NOT to diagnose PMOS in teens. You need both irregular cycles and hyper-androgenism. Should not assess cycles until at least 2 years of menarched, AND polycystic ovarian morphology (PCOM) should NOT be used within 8 years of menarche. Additionally AMH should not be used.

Typical vs. Atypical

• In functionally typical PMOS, overexpression of DENND1A.V2 leads to hypersecretion of testosterone precursors from the theca cells. Plus 20-30% of the time, there is adrenal contribution with also elevated DHEA.
• In functionally atypical PMOS, obesity mediated insulin resistance and excess leads to stimulation of steroidogenesis and overproduction of androgens within adipocytes

Additional evaluation after diagnosing PMOS should include: 

1. Cardio-metabolic risk assessment: HbA1c, lipids, STOP-BANG (for OSA) 
2. MASLD
3. Depression and anxiety
4. Anovulatory infertility
5. (there is an elevated risk for endometrial cancer but screening is generally NOT recommended)

Management

management of PMOS depends primarily on desire for fertility

goals include: management of hyperandrogenic features, management of underlying metabolic abnormalities, prevention of endometrial hyperplasia and cancer, contraception (for those not desiring pregnancy) and ovulation induction (for those who desire pregnancy)

For those who do NOT want to pursue pregnancy:

Endometrial protection with pills/patch/ring (combined contraceptives) are first line to manage hyperandrogenism, cycle regularity and contraception. Progestin only products are acceptable but do not manage hyperandrogen. Metformin can help with menstrual regularity.

Certain progestins have less androgenic activity (see image)

You can add spironolactone after 6 months for additional anti-androgen effect PRN

For those who DO want to pursue pregnancy:

Ovulation induction is the goal with either letrozole (now first line) or clomiphene

Metformin does not help with ovulation dysfunction except for patients with insulin resistance who have failed lifestyle interventions (diet, weight loss)

Addition of a supplement called inositol has increasing evidence for ovulation induction

Additional dietary supplements to consider: Vitamin D, Omega 3, NAC, berberine

Why Discharge Before Noon. . and other Hospital Metrics (Picetti, 9/9/2026)

A recording of this presentation is available HERE.

Thanks to Dr. Dominic Picetti, hospitalist and physician advisor at SSRRH, who gave an important presentation on Reimagining Care Progression.

He started with this article from the Choosing Wisely Campaign "Things We Do for No Reason", which debunks this oft-used metric as a means to decrease length of stay (LOS) and create more open beds for patients waiting in the ED.



While Dr. Picetti acknowledged that using this metric in isolation does not accomplish the goals stated above, he reminded us that prolonged ER boarding DEFINITELY leads to worse outcome (increased mortality, increased CAUTI, increased CLABSI, increased falls, increased delirium and a poor experience of the hospital).


However, arbitrary clock time metrics fail to solve hospital overcrowding because they target an order entry deadline rather than underlying operational throughput barriers.


How can we improve this quality? We can do so by implementing a multi-disciplinary care progression model, which considers "steps to home" from the beginning-- what is the estimated/target discharge date? what are barriers to this patient going home? There is evidence to support these models (see image below)





AHRQ states that daily multi-disciplinary rounds are the single most effective lever to decrease hospital days in complex patients.


We must consider the concept of throughput:
From ER (where we establish early trust or mistrust)--> Inpatient/on wards, where clarity vs. lack of clarity defines the patient experience (there are plenty of opportunities here for mistrust). One of the goals of multidisciplinary rounds is to establish the anticipated date of discharge and share that with the patient. It is okay if we are wrong, but better to give the information to the patient.


In other words, "discharge should start on day #1".


Dr. Picetti also lifted up the statement Why not home? Why not today? as a conversation to be had with and about each patient each day. Our goal should be for patients to spend LESS time in the hospital (because generally being at home is better for everyone) and ultimate disposition location should be home.


One of our jobs is to inform people when they are medically ready to leave the hospital.


***


Quality Metrics are measure of the quality of care we provider patients.


When patients spend extra days in an acute hospital bed (beyond medical readiness), patients are at increased risk of lots of things: CAUTI, CLABSI, pressure injuries, falls, delirium. All of these contribute to increased readmission AND increased morbidity and mortality.


The Sutter Playbook is a framework for understanding Inpatient progression. It includes:
1) Case management does an assessment <24 hours from admission. Goals are to identify post-acute placement needs, prior living arrangements, PCP, DME, social barriers
2) Daily MDRs why not home? why not today?
3) Real time delay tracking (case management does this in the "avoidable delay" tab on Epic)
4) Touch points (2pm meeting with leaders AND complex care rounds weekly, where all patients > 7 days and other challenging cases are discussed)

Caring for the Post C-section Patient (Morrison, 9/2/2026)

A recording of this presentation is available HERE.

Thanks to Dr. Lily Morrison, R3 for a really thoughtful and important presentation on Caring for the Post-C-section Patient. Dr. Morrison shared her own learning after herself experiencing an emergency c-section last year. She did a wonderful job of marrying the evidence (qualitative and quantitative) and the patient experience (her own and that which is captured online and in the qualitative evidence) in her presentation. I highly recommend you watch it! If you just want the Cliff's notes, here they are:

>1,000,000 c-sections occur annually (about 1/3 of all US births)

C-section is the most common major surgery performed in this country

When Dr. Morrison had her c-section, she admits, she didn't really know what to expect, and as she dove into the literature, she was not alone:

Hospital discharge instructions given to Dr. Morrison did not answer her most basic questions-- e.g. when can I pick up my toddler and when is it safe to drive and return to other typical activity?

Dr. Morrison divided her presentation into first hours>> first days>> first 6 weeks>> first 3 months>> chronic as a way to think about post-op C-section care

The most updated evidence-based immediate C-section Guidelines come from Enhanced Recovery After C-section (ERAC) 2025 Update from the Society of Obstetric Anesthesia and Perinatology. This really outlines important actions while in the hospital after a c-section.

First 48 hours

Pain is obviously an important outcome after c-section and patient experience is highly variable

EARLY pain control is known to have positive impact long after the immediate post-op period

Standard care involves:

1) Neuraxial opioids in the first 12 hours after surgery (spinal/epidural during c-section by anesthesia)

2) For patients who have had a crash c-section under general anesthesia, consider ways to augment pain control including a transversus abdominus plane (TAP) block, which can be done by anesthesia

3) There is good evidence for 1gm of APAP pre-op

4) Scheduled ibuprofen/APAP after surgery (for weeks for some patients)

5) Opiates as a rescue (we generally use oxy in our hospital, oral is preferred to IV and try to limit to <30mg/first 24 hours)

6) Abdominal binders has mixed recommendations but does have evidence for improved early pain 

Early function (i.e. encourage patient to walk) also has evidence. Walking ASAP after surgery leads to fewer complications (9716 steps during hospitalization showed significantly less complications), early showering (after 12 hours is fine, no need to wait 48 hours), early eating and drinking, early foley removal

Psychological healing: normalize the experience, help limit the guilt/shame of not having had a vaginal delivery, recognize for some women they have experienced a trauma, acknowledge their disappointment and grief. Some women really benefit from debriefing early (others needs/want it later)

Infant bonding: also important, pain control and encourage breastfeeding, skin to skin

First 6 weeks

Pain 

median time to opioid cessation is 8 days

median time to analgesic cession 17 days

median time to pain resolution 21 days

There appears to be an inflection point for patients in pain at the 3 week mark-- 22 days +/- 9 (this is GOOD to share with patients). This means that pain is normal to still be experiencing  at the 2 week visit, it is okay to continue APAP/Ibuprofen, keep using the binder

Function

There are really NO evidence based guidelines, really pain should be the guiding factor for everything from lifting to driving to having sex

Psychological healing

there are increased rates of post partum depression and anxiety after LTCS, 20-40% of women with PPD in c-section patients, 4-20% with PTSD

Screen! 

Treat with SSRI (sertraline has the best evidence), CBT

Address PPD and PTSD as a care team: stigma, disappointment, a sense of failure, poor communication, a lack of trust, loss of control, fear of the OR can all be normal>> consider addressing some of these expectations prenatally (since 1/3 pregnancies in the US will end in LTCS)

Post C-section debrief>> some patients do not want to revisit the event, but some DO!

Goal is rebuilding TRUST

Next 3 months

Pain

After 3 months, if patients still have pain, this should be considered "chronic"

~1/4 of patients after LTCS report chronic pain, likely 2/2 nerve entrapment, intrabdominal adhesions

Risk factor for chronic pain include: severe early post-op pain (this is why we want to treat pain EARLY), stress, smoking, pre-op depression or anxiety, and longer/more complex surgery

Treatment for chronic post-c-section pain:

1- rule out something medical (surgical referral for lysis of adhesions)

2-offer meds (SNRI, gabapentin)

3-physical therapy (scare and soft tissue mobilization)

4-topical medications (e.g. capsaicin, lidocaine)

5-acupuncture (there is an evidence based modality called "scar deactivation", protocolized)

6-lidocaine infiltration can be done 30-66 of 0.5% lidocaine significantly can improved pain (has been effective in early post-partum period as well)

Return to Exercise

Day 1: gentle walking pelvic flood exercises

2-6 weeks gentle abdominal engagement, increased walking, aim for 30 minutes 5x/week

6-8 weeks the abdominal fascia has 51-59% of its tensile strength

8-12 weeks high intensity, low impact 

>12 weeks running/circuit training/full exercise

Reasons to slow down: severe pain, increased vaginal bleeding, excessive fatigue

Long term impact of birth method:

~5% of c-section patients still experience pain >1 year after surgery

Life long increased risk of miscarriage, previa, stillbirth and abruption

Of note, c-section patients have lower rates of urinary incontinence and prolapse