Impact of an Antibiotic Side-Chain–Based Cross-reactivity Chart Combined With Enhanced Allergy Assessment Processes for Surgical Prophylaxis Antimicrobials in Patients With β-Lactam Allergies

Abstract

Background β-Lactam antibiotics are first-line therapy for perioperative prophylaxis; however, patient-reported allergies often lead to increased prescribing of alternative antibiotics that may increase the incidence of surgical site infections. The R-group side chain of the β-lactam ring is responsible for allergic cross-reactivity and experts recommend the use of β-lactams that are structurally dissimilar. Methods An internally developed, antibiotic side-chain–based cross-reactivity chart was developed and implemented alongside enhanced allergy assessment processes. This single-center, quasi-experimental study analyzed antibiotic prescribing in all adult patients with a documented β-lactam allergy undergoing an inpatient surgical procedure between quartile (Q) 1 (2012)–Q3 (2014) (historical group) and Q3 (2016)–Q3 (2018) (intervention group). Propensity-weighted scoring analyses compared categorical and continuous outcomes. Interrupted time-series analysis further analyzed key outcomes. Results A total of 1119 and 1089 patients were included in the historical and intervention cohorts, respectively. There was a significant difference in patients receiving a β-lactam alternative antibiotic between cohorts (84.9% vs 15.1%; P < .001). There was a decrease in 30-day readmissions in the intervention cohort (7.9% vs 6.3%; P = .035); however, there was no difference in the incidence of SSIs in patients readmitted (14.8% vs 13%; P = .765). No significant differences were observed in allergic reactions (0.5% vs 0.3%; P = .323), surgical site infections, in-hospital and 30-day mortality, healthcare facility–onset Clostridiodes difficile infection, acute kidney injury, or hospital costs. Conclusions Implementation of an antibiotic cross-reactivity chart combined with enhanced allergy assessment processes significantly improved the prescribing of β-lactam antibiotics for surgical prophylaxis.

Antibiotic Use in Patients With β-Lactam Allergies and Pneumonia: Impact of an Antibiotic Side Chain–Based Cross-Reactivity Chart Combined With Enhanced Allergy Assessment

“…These results are similar to previously reported results from our institution, which detailed significant improvements in β-lactam selection for surgical prophylaxis [ 27 ]. Analyses across similar time periods show increased prescribing resulting in 85% and 89% β-lactam use for surgical prophylaxis and pneumonia, respectively.…”

“…A previous analysis at our institution showed significant improvements in β-lactam prescribing for surgical prophylaxis with no increase in incidence of allergic reactions following introduction of an antibiotic side chain–based cross-reactivity chart and enhanced allergy assessment processes [ 27 ]. We describe the impact of our approach for the management of patients with β-lactam allergies on antibiotic use in patients with pneumonia.…”

Impact of a Mortality Prediction Rule for Organizing and Guiding Antimicrobial Stewardship Program Activities

“…Our ASP also had several initiatives running concurrently that likely impacted results. Initiatives impacting all patients regardless of mortality scoring included extensive facility-specific guideline development, promotion of β-lactam prescribing utilizing allergy cross-reactivity guidelines, and targeted syndrome-specific interventions including diagnostic stewardship with focus on common infectious diseases such as pneumonias and UTIs [ 18–22 ].…”

Penicillin allergies

“…However, several useful variations have shown promise in previous studies. 15,24,[27][28][29] Allergy assessment does not need to be reserved for patients who actively need antibiotics; it may be best to do at routine offi ce visits as it may prevent future delays in antibiotic treatment. The most important points to establish in an allergy history are as follows: (1) what medication caused the reaction, ( 2) what reaction or symptoms occurred, (3) how soon after…”