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Alternative Antibiotic Use in Patients with Reported Penicillin Allergy: An Opportunity for Antibiotic Stewardship
EP28798
Alternative Antibiotic Use in Patients with Reported Penicillin Allergy: An Opportunity for Antibiotic Stewardship
Submitted on 09 Jul 2018

Cara Iorianni MD, Terry Langfitt MD, Galaxy Mudda MD, Tiffany Lee MD, Andrew Bowman MD, Jimmy Yao MD, Ben Amoateng MPH, Vikas O'Reilly-Shah MD, PhD, Grant Lynde MD, MBA, Francis Wolf MD​
Emory University School of Medicine, Department of Anesthesiology
This poster was presented at Georgia Society of Anesthesiologists Summer Meeting
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Poster Abstract
Introduction

Postoperative infections are reduced by timely administration of appropriate prophylactic antibiotics. Cefazolin, a first-generation cephalosporin, is the recommended first line agent for most surgical procedures. Although cefazolin can be safely administered to most patients with a reported penicillin allergy, anesthesia providers may substitute a second-line antibiotic such as vancomycin or clindamycin due to concerns for cross-reactivity. The disadvantages of second-line antibiotics may include decreased efficacy, increased cost, adverse effects, decreased compliance with on-time administration, and the emergence of antibiotic resistance. As part of a quality improvement project, we aimed to determine the prevalence of reported penicillin allergy among surgical patients at our hospital and the preoperative antibiotics used. We also assessed whether penicillin allergy was associated with worse compliance with timely administration of antibiotics and increased rates of postoperative infections.

Methods

We analyzed electronic medical records from general, vascular and plastic surgery cases from a 3-year period (2014-2016) at a single academic hospital. Penicillin allergies were identified by assessing all allergies in the electronic medical record using generic and trade names for aminopenicillins, antipseudomonal penicillins, beta-lactamase inhibitors, natural penicillins and penicillinase resistant penicillins. We compared rates of cefazolin administration versus alternative antibiotics for patients with and without penicillin allergy. Postoperative infections (surgical site infections and sepsis) were identified using data from the National Surgery Quality Improvement Project (NSQIP) and compared between the two groups. Timely administration of the initial antibiotic dose was evaluated using institutional practice guidelines.

Results

6,121 surgical cases were analyzed for allergy, antibiotic administration and postoperative infection data: 58% were female, 73% were general surgery cases, and 55% were American Society of Anesthesiologists Physical Status 3. The prevalence of reported penicillin allergy was 14.6% (n=982). Among patients with a reported penicillin allergy, 8.6% received cefazolin compared to 88.5% of patients without a penicillin allergy (p<0.0001). The most common alternate antibiotics given to patients with a penicillin allergy were clindamycin (41%), aztreonam (24%), vancomycin (13%) and levofloxacin (7.8%). Failure of on-time initial dose antibiotic administration occurred in 16.6% of patients with a penicillin allergy compared to 8.6% of those without a penicillin allergy (p<0.0001). There was a trend towards increased postoperative infectious complications in patients with a penicillin allergy (9% vs 7.2%, OR 1.26 95% CI 0.98 to 1.62, p=0.07).

Discussion

Over 90% of patients with a reported penicillin allergy do not have a true allergy. Additionally, cross-reactivity with cefazolin is unlikely due to lack of similarity in the molecular side chains. Because anesthesiologists administer surgical antibiotic prophylaxis, we are important in the promotion of antibiotic stewardship by decreasing the use of alternate antibiotics through preoperative assessment of patient allergies and rational use of cefazolin. Promoting the use of the preferred first line cephalosporins over alternative agents may reduce the rates of postoperative wound infections through improved protocol compliance and antibiogram optimization.

1. Zagursky RJ, Pichichero ME. Cross-reactivity in β-Lactam Allergy. J Allergy Clin Immunol Pract. 2018 Jan - Feb; 6(1):72-81.

2. American Academy of Allergy, Asthma & Immunology. Choosing Wisely. Don’t overuse non-beta lactam antibiotics in patients with a history of penicillin allergy, without an appropriate evaluation. www.choosingwisely.org. Accessed May 15, 2018

3. Blumenthal KG, Ryan EE, Li Y, Lee H, Kuhlen JL, Shenoy ES. The impact of a reported penicillin allergy on surgical site infection risk. Clin Infect Dis. 2018 Jan; 66(3);329-336
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