Issue: January 2021
Disclosures: Blumenthal reports a beta-lactam allergy clinical decision support tool licensed to Persistent Systems.
December 11, 2020
2 min read
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Documented beta-lactam allergy increases odds for riskier surgical prophylaxis antibiotics

Issue: January 2021
Disclosures: Blumenthal reports a beta-lactam allergy clinical decision support tool licensed to Persistent Systems.
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Surgical patients with a documented beta-lactam allergy were nine times less likely to receive the preferred first-line antibiotic cefazolin but more likely to receive riskier, alternative antibiotics, according to a recent study.

“Perioperative administration of antibiotics is a common strategy used to prevent surgical site infections,” Kimberly G. Blumenthal, MD, MSc, quality and safety officer for allergy at Massachusetts General Hospital and assistant professor of medicine at Harvard Medical School, told Healio, noting that it is typically left to the surgeon’s discretion to select the antibiotic for surgical prophylaxis. “Cefazolin is preferred for a majority of surgical procedures because of proven efficacy; however, cefazolin is a beta-lactam antibiotic, and it may be avoided in patients with a reported allergy to beta-lactam antibiotics like penicillin.”

Cefazolin infographic
Source: Bertram CM, et al. Clin Infect Dis. 2020;doi:10.1093/cid/ciaa1762.

She added, “We wanted to see if this was true in a large sample of patients because more than 95% of those reporting a penicillin allergy are not truly allergic, and cefazolin has low — or potentially even negligible — cross-reactivity with penicillin.”

To evaluate the impact of a documented beta-lactam allergy on perioperative antibiotic selection, Blumenthal and colleagues performed a national cross-sectional study of hospitalized patients through Vizient Inc.’s Acute Care Hospital Group. According to the study, a designee from the Vizient member hospitals completed an intake survey

that included hospital details and beta-lactam allergy assessment resources. Participant sites then submitted clinical details for inpatients treated with any antibiotic within the study period Oct. 16, 2018, to Jan. 13, 2019 using electronic health records and antibiotic utilization data.

A study demonstrated that surgical inpatients with a documented beta-lactam allergy were nine times less likely to receive the preferred antibiotic for prophylaxis — cefazolin — and they were 45 times more likely to instead receive clindamycin, despite the drug’s known risks.
Credit: Adobe Stock

In total, 1,632 surgical patients from 100 U.S. hospitals were included in the study. The researchers noted that inpatient allergy consultations were available at 37 of the hospitals and inpatient penicillin skin testing was available at 29. Additionally, almost all hospitals (96%) had a formalized antibiotic stewardship program.

The study demonstrated that of the 1,632 patients who received antibiotics for surgical prophylaxis, 256 (16%) had a documented beta-lactam allergy, with 224 (88%) having a documented allergy to penicillin and 48 (19%) to cephalosporins. According to the study, cefazolin was less frequently used in patients reporting a beta-lactam allergy compared with patients who did not report one (28% vs 77%). Alternative antibiotics used more frequently in patients with a documented beta-lactam allergy included vancomycin (24% vs. 11%), fluoroquinolones (6% vs 2%), clindamycin (32% vs 1%) and gentamicin (11% vs 3%).

Kimberly G. Blumenthal

A fully adjusted multivariable regression model demonstrated that patients with a documented beta-lactam allergy had lower odds of cefazolin use (adjusted OR = 0.11; 95% CI, 0.08-0.15) compared with those without a documented beta-lactam allergy. Additionally, patients with a documented beta-lactam allergy had higher odds of receiving perioperative clindamycin (aOR = 45.6; 95% CI, 24.8-83.4) and increased odds of receiving gentamicin (aOR = 3.9; 95% CI, 2.36-6.42), fluoroquinolones (aOR = 3.11; 95% CI, 1.66-5.84) and vancomycin (aOR = 2.91; 95% CI, 2.05-4.13).

“This study demonstrates the importance of incorporating beta-lactam allergy evaluations, which disprove reported beta-lactam allergies in more than 95% of patients, into preoperative care to optimize the selection of antibiotics for surgical prophylaxis,” Blumenthal said.