Impact of the Allergy Clarification for Cefazolin Evidence-based Prescribing Tool on Receipt of Preferred Perioperative Prophylaxis: An Interrupted Time Series Study

Lam, Philip W; Tarighi, Payam; Elligsen, Marion; Nathens, Avery B.; Riegert, Daniel; Tarshis, Jordan; Leis, Jerome A

doi:10.1093/cid/ciaa516

“…Similarly, the cross-reactivity risk between penicillins and carbapenems is even lower around 0.8%-1.0% [10,[43][44][45]. Given the low cross reactivity, some authors have administered cephalosporins to patients with penicillin allergies without skin testing using simple screening tools to screen for significant allergies [46,47]. While this is a reasonable approach, penicillin skin testing remains a consideration, particularly when the nature of the allergy is unclear.…”

Section: Discussionmentioning

confidence: 99%

Documented β-Lactam Allergy and Risk for Cesarean Surgical Site Infection

Johnston

¹

,

Godecker

²

,

Shirley³

et al. 2022

Infectious Diseases in Obstetrics and Gynecology

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Objective. To examine the relationship between documented β-lactam allergy and cesarean delivery (CD) surgical site infection (SSI). Study Design. We conducted a retrospective cohort analysis of women who underwent CD at Ben Taub Hospital and Texas Children’s Pavilion for Women (Houston, TX) from August 1, 2011, to December 31, 2019. The primary exposure was a documented β-lactam allergy, and the second exposure of interest was the type of perioperative antibiotic received. The primary outcome was the prevalence of SSI. Maternal characteristics were stratified by the presence or absence of a documented β-lactam allergy, and significance was evaluated using Pearson’s chi-squared test for categorical variables and t -test for continuous variables. A logistic regression model estimated odds of SSI after adjusting for possible confounders. Results. Of the 12,954 women included, 929 (7.2%) had a documented β-lactam allergy while 12,025 (92.8%) did not. Among the 929 women with a β-lactam allergy, 495 (53.3%) received non-β-lactam perioperative prophylaxis. SSI occurred in 38 (4.1%) of women who had a β-lactam allergy versus 238 (2.0%) who did not ( p ≤ 0.001 ). β-Lactam allergy was associated with higher odds of SSI compared to no allergy ( adjusted odds ratio aOR = 1.97 ; 95 % confidence interval CI = 1.24 -3.14; p = 0.004 ) after controlling for age, race, ethnicity, insurance status, delivery body mass index (BMI), tobacco use, intra-amniotic infection in labor, duration of membrane rupture, preterm delivery, delivery indication, diabetes, hypertension, group B Streptococcus colonization, and type of perioperative antibiotic received. Conclusion. The presence of a β-lactam allergy is associated with increased odds of developing a CD SSI after controlling for possible confounders, including the type of perioperative antibiotic received.

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“…Outpatient penicillin allergy testing during pregnancy has shown promise in reducing the use of broad-spectrum antibiotics [ 7 , 17 ]. In addition, cross-reactivity of cephalosporins to penicillins is overestimated [ 16 ], and quality improvement studies to encourage cefazolin use for surgical prophylaxis in penicillin-allergic patients found no cases of anaphylaxis [ 18 , 19 ], including in 1 study that used cefazolin even for patients with histories of severe IgE-mediated hypersensitivity reactions to penicillin [ 20 ]. For GBS prophylaxis in patients with penicillin or cephalosporin allergies, a standardized allergy-guided order set increased appropriate antibiotic use from 47% to 85% [ 21 ].…”

Section: Discussionmentioning

confidence: 99%

Appropriate Antibiotic Use for Group B Streptococcus Prophylaxis Among Penicillin-Allergic Patients in Academic and Nonacademic Hospitals

Pineles

¹

,

Goodman

²

,

Pineles

³

et al. 2022

Open Forum Infectious Diseases

3

0

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This study estimated prophylactic antibiotic usage rates for the prevention of early-onset invasive neonatal group B Streptococcus infection among patients with penicillin allergy. Undertreatment (no antibiotics, underuse of cefazolin, overuse of clindamycin inconsistent with resistance patterns) and overtreatment (vancomycin use) were common. Academic hospitals were marginally more adherent to guidelines than nonacademic hospitals.

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“…Finally, this study was conducted within a single institution, and it is unknown whether our findings can be extrapolated to other institutions, although a recent study identified a similar increase in perioperative cephalosporin utilization in penicillin-allergic patients with implementation of an algorithm at clinic visits prior to elective surgeries, which is encouraging with respect to generalizability. 23 In conclusion, we present a low-cost, low-effort intervention centered around provider education to optimize perioperative antimicrobial prophylaxis in the setting of self-reported penicillin allergy, with associated cost savings. We will continue to monitor antibiotic utilization in these patients, with additional reinforcement of the algorithm if necessary.…”

Section: Discussionmentioning

confidence: 99%

Anatomy of a successful stewardship intervention: Improving perioperative prescribing in penicillin-allergic patients

Sexton

¹

,

Kuruvilla

²

,

Wolf

³

et al. 2021

Infect. Control Hosp. Epidemiol.

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Objective: To evaluate whether a series of quality improvement interventions to promote safe perioperative use of cephalosporins in penicillin-allergic patients improved use of first-line antibiotics and decreased costs. Design: Before-and-after trial following several educational interventions. Setting: Academic medical center. Patients: This study included patients undergoing a surgical procedure involving receipt of a perioperative antibiotic other than a penicillin or carbapenem between January 1, 2017, and August 31, 2019. Patients with and without a penicillin allergy label in their electronic medical record were compared with respect to the percentage who received a cephalosporin and average antibiotic cost per patient. Methods: A multidisciplinary team from infectious diseases, allergy, anesthesiology, surgery, and pharmacy surveyed anesthesiology providers about their use of perioperative cephalosporins in penicillin-allergic patients. Using findings from that survey, the team designed a decision-support algorithm for safe utilization and provided 2 educational forums to introduce this algorithm, emphasizing the safety of cefazolin or cefuroxime in penicillin-allergic patients without history of a severe delayed hypersensitivity reaction. Results: The percentage of penicillin-allergic patients receiving a perioperative cephalosporin improved from ∼34% to >80% following algorithm implementation and the associated educational interventions. This increase in cephalosporin use was associated with a ∼50% reduction in antibiotic cost per penicillin-allergic patient. No significant adverse reactions were reported. Conclusions: An educational antibiotic stewardship intervention produced a significant change in clinician behavior. A simple intervention can have a significant impact, although further study is needed regarding whether this response is sustained and whether an educational intervention is similarly effective in other healthcare systems.

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Impact of the Allergy Clarification for Cefazolin Evidence-based Prescribing Tool on Receipt of Preferred Perioperative Prophylaxis: An Interrupted Time Series Study

Cited by 19 publications

References 10 publications

Documented β-Lactam Allergy and Risk for Cesarean Surgical Site Infection

Documented β-Lactam Allergy and Risk for Cesarean Surgical Site Infection

Appropriate Antibiotic Use for Group B Streptococcus Prophylaxis Among Penicillin-Allergic Patients in Academic and Nonacademic Hospitals

Anatomy of a successful stewardship intervention: Improving perioperative prescribing in penicillin-allergic patients

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