Perioperative Use and Safety of Cephalosporin Antibiotics in Patients with Documented Penicillin Allergy

Abstract

Questions remain regarding safest strategies for cephalosporin administration in patients with listed penicillin allergy (PA). This is highly relevant in the peri-operative setting, where unnecessary avoidance of first-line cephalosporins is associated with increased surgical site infections. Between 6/23/2015–5/31/2018, anesthesia records of adult surgical encounters for patients with listed PA at a tertiary care center were reviewed for age, gender, drug allergies, and peri-operative medications administered. Allergic hypersensitivity reactions (HSR) were graded per NIAID/FEEN criteria. Statistical analyses were conducted in Stata15. Of 8,770 patients with listed PA, 37.9% [3324/8770] received full doses of peri-operative beta-lactam antibiotics (cefazolin 77.3% [2570/3324], 3rd-5th generation cephalosporins 10.0% [334/3324]), 18.2% [1597/8770] received clindamycin, and 37.4% [3279/8770]) received no antibiotic. Nine HSR occurred (0.10% [9/8770]) in those with a PA. Two HSR occurred after beta-lactam administration (both to cefazolin; anaphylaxis in 0.04% [1/2,570]; mild reaction in 0.04% [1/2,570]) in patients with mild documented penicillin reactions (non-urticarial rash, itching). Patients with documented penicillin anaphylaxis had no observed HSR to any beta-lactams. The relative risk of HSR in patients with a PA who received clindamycin, cefazolin, or no antibiotics were 8.98 [95%CI 2.25-35.88], 0.69 [0.14-3.32], and 0.48 [0.10-2.30] respectively. This study provides further evidence that patients with listed PA can receive most cephalosporin antibiotics safely. HSR rates were comparable between cefazolin and clindamycin, highlighting the lack of cross-reactivity between penicillin and cefazolin. Data indicate that cefazolin and 3rd-5th generation cephalosporins can be administered as full doses without penicillin skin testing, even in patients with documented penicillin anaphylaxis.