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Revisiting perioperative penicillin allergy to optimize cefazolin use

Published online: December 28, 2019

Surgical patients with a penicillin allergy are more likely to receive second-line antibiotics as opposed to first-line cephalosporins (cefazolin/cefuroxime), and have increased risk for surgical site infections and side effects. Provider misconceptions about cross-reactivity risk likely drive this prescribing behavior. However, only 1-10% of penicillin allergy labels are real. Further, the rate of clinically significant cross-reactivity between penicillins and cephalosporins is now recognized to be as low as 2-5% and this risk is even lower for cefazolin and cefuroxime.

In a study recently published in The Journal of Allergy and Clinical Immunology: In Practice, Kuruvilla et al describe outcomes of a multi-disciplinary practice improvement effort with the goal of increasing the use of first-line prophylactic antibiotics in surgical patients. They present a streamlined approach for evaluation of penicillin allergy in preoperative patients, to allow for safe administration of prophylactic cephalosporins without additional testing.

The percentage of patients receiving a first-line cephalosporin increased from 22% at baseline to >80% following algorithm implementation. Among 551 patients with penicillin allergy label who received a cephalosporin, there were no immediate or delayed hypersensitivity reactions attributable to cefazolin or cefuroxime use. These initial results suggest that the use of a streamlined algorithm without antecedent penicillin allergy testing can increase perioperative cephalosporin utilization without a significant risk of adverse reactions.

The Journal of Allergy and Clinical Immunology: In Practice is an official journal of the AAAAI, focusing on practical information for the practicing clinician.

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