60. Beta-lactam antibiotic surgical prophylaxis is safe in patients with self-reported penicillin allergies: a cohort study of lumbar spine surgery patients

Abstract

BACKGROUND CONTEXT The use of first-generation cephalosporins for perioperative antibiotic prophylaxis in elective spine surgery is strongly recommended. Patients with self-reported penicillin (PCN) allergies are often administered suboptimal alternative antibiotics given the concern for distant cross-reactivity. The reliability of patient-reported PCN allergies has been disputed and is poorly understood. PURPOSE To determine the safety of administering perioperative beta-lactam antibiotics prior to lumbar spine surgery in patients reporting a penicillin (PCN) allergy. STUDY DESIGN/SETTING Retrospective cohort at tertiary referral hospital. PATIENT SAMPLE All patients undergoing lumbar spinal surgery at a single, large academic medical center between 2015-2016 was performed. Patients with a self-reported PCN allergy that were referred to a Drug Allergy Clinic for allergy testing were included in the study. OUTCOME MEASURES The primary outcome measure was comparison of penicillin skin-testing results with patient reported PCN allergies and a secondary outcome was the safety of perioperative cephalosporin administration. METHODS Patients were identified by use of an automated best practice advisory prompt within the electronic health record if the patient's medical record included an allergy to any penicillin derivatives or any of the 116 different cephalosporins. The advisory prompted referral to the Drug Allergy Clinic (DAC) for evaluation. Within the DAC, a detailed history about the patient allergies, specifically beta-lactam antibiotics, was obtained. If there was a clinical concern, evaluation proceeded with the use of penicillin skin testing techniques and appropriate controls. Negative testing resulted in allergy removal and surgery proceeded with the use of appropriate first generation cephalosporins. Complications relating to administration were recorded. RESULTS Twenty-nine patients undergoing lumbar spine surgery with reported PCN allergies were referred to the Drug Allergy Clinic for evaluation. Of these referrals, 19 patients were completely evaluated and underwent penicillin skin-testing (PST) or had no intervention depending on the history obtained. PST was performed on 17 patients (89%), while no testing was indicated in 2 patients as an allergy was ruled out by the history. A negative PST was noted in all 17 (100%) patients tested. Cefazolin was deemed safe to use in all 19 patients (100%) evaluated. All 19 patients underwent a lumbar spine surgery with a first-generation cephalosporin used for perioperative antibiotic prophylaxis without any adverse peri-operative reactions. CONCLUSIONS Patients with a self-reported history of PCN allergy are unlikely to have a reaction to beta-lactam antibiotics administered in the perioperative setting. A strong consideration should be given to routine cephalosporin use despite reported PCN allergies. Referral to a Drug Allergy Clinic for PST is an option for those with more concerning medical or family histories. FDA DEVICE/DRUG STATUS This abstract does not discuss or include any applicable devices or drugs.