InfectionDe-labeling of β-lactam allergy reduces intraoperative time and optimizes choice in antibiotic prophylaxis☆
Introduction
Antimicrobial resistant infections affect more than 2 million people in the United States and result in about 23,000 deaths annually, at an estimated cost of $55 billion USD.1 The prescription of “antibiotics of last resort” (such as carbapenem) is of major concern, because of an increase in reported cases of resistance to these antibiotics due to over-prescription.2, 3
Penicillins remain among the most commonly prescribed antibiotics worldwide.4, 5, 6, 7 They provide many advantages; including high effectiveness, low cost, and minimal side effects.8 Unfortunately, about 10% of the general population carries a label of penicillin allergy.9, 10, 11 Among those who claim to be penicillin allergic, 90% are not truly allergic when properly evaluated.12, 13 Intolerance and non-specific adverse events are often inappropriately attributed to penicillin allergy. This in turn leads to the prescription of inappropriate antibiotics that contribute to the development of antibiotic resistance.
The American Academy of Allergy, Asthma & Immunology points out that without β-lactam testing, an unverified history of penicillin allergy can contribute to higher costs and greater risk for adverse effects from alternative non-β-lactam antibiotics, along with increased rates of serious antibiotic resistant infections such as c.difficile and methicillin-resistant staphylococcus aureus.14
Surgical site infections are a common cause of healthcare-related infections.15, 16 Perioperative antimicrobial prophylaxis is implemented in order to lessen the chance of microorganisms taking hold at the site of surgery during the procedures.17 The most commonly used antibiotics in perioperative prophylaxis are cefazolin and vancomycin. Cefazolin, a first generation cephalosporin, is the drug of choice due to its antimicrobial effectiveness, reasonable cost, and a short duration of action.18 In cases of suspected β-lactam allergy, vancomycin is the most commonly prescribed alternative despite some major drawbacks, such as longer administration time (approximately an hour)19 and significant side effects—red man syndrome,20 nephrotoxicity, and ototoxicity.21 Patients with a reported penicillin allergy have 50% increased odds of surgical site infections, attributable to use of second-line perioperative antibiotics. These infections incur an estimated cost exceeding $25,000 USD per case.22
A systematic institutional approach to confirming penicillin allergy is not currently implemented in many large Canadian hospitals and as a result, patients are often permanently labeled allergic to penicillin. Given the obvious need to clarify suspected penicillin allergy status, a service and protocol to provide preoperative evaluation of possible β-lactam allergy was established at the Montreal General Hospital (MGH) (Fig 1) using standardized prescriptions, policies, procedures, and a risk assessment tool (Fig 2). A need to determine the value of this service was identified.
Section snippets
Study Design
Standardized drug allergy testing was initiated in January 2015 when policies, standard operating procedures, and consent forms were created. The preoperative staff was engaged to facilitate the referral process; patients were evaluated on the same day as their regular scheduled preoperative visit. A mandatory risk assessment tool defined the level of challenge required for each patient. Experienced clinical staff performed the clinical evaluations and drug testing. Higher risk patients
Results
There were 255 patients referred for allergy testing prior to scheduled surgery from April 1, 2015 to March 31, 2017. Of these, 61 were excluded because they did not meet the study criteria as they did not undergo surgery within 6 months of their testing, underwent surgery at another institution, were deceased, or had incomplete files. The EMRs of the 194 patients meeting the eligibility criteria were reviewed for completeness and accuracy of data. Data collection forms were used to transcribe
Discussion
Comprehensive penicillin allergy evaluation successfully de-labeled 94.3% of patients referred for preoperative β-lactam allergy evaluation. By identifying patients who were truly penicillin allergic, vancomycin was used only in five surgeries (3%) and cefazolin was subsequently prescribed for 120/155 (77.4%) of the de-labeled patients that received prophylactic antibiotics. Despite the preoperative evaluation and the allergist recommendation, for unknown reasons, two out of seven patients that
Acknowledgment
This work was supported through the generosity of the Anna-Maria Solinas Laroche Allergy and Clinical Immunology Research fund and the Montreal General Hospital Foundation. We would like to thank members and staff of the MUHC Division of Allergy and Clinical Immunology, the Department of Surgery, the preoperative clinic for their collaboration, Dr. Paul Tsoukas for illustration assistance, and Mrs. D. Cutler for manuscript editing.
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2021, Journal of Allergy and Clinical ImmunologyCitation Excerpt :Of the 122 articles meeting the eligibility criteria, 17 were excluded because some participants had also been assessed (receiving the same tests) by studies assessing larger samples. Therefore, a total of 105 studies were included in this systematic review.13,22-125 For studies in which some degree of participant overlap with other study(ies) occurred (see Table E2 in this article’s Online Repository at www.jacionline.org),36,37,40-42,59,62,69,72,83,106,109 we presented only unique information from each study (eg, results from diagnostic tests performed in 1 study that had not been performed in the other study assessing the same participants), so that no participant has been included more than once.
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The Anna-Maria Solinas Laroche Allergy and Clinical Immunology Research fund of the Montreal General Hospital Foundation provided funding for this study.