SLR - April 2022 - Andrea C. Batra
Reference: Goh GS, Shohat N, Austin MS. A Simple Algorithmic Approach Allows the Safe Use of Cephalosporin in "Penicillin-Allergic" Patients without the Need for Allergy Testing. J Bone Joint Surg Am. 2021 Dec 15;103(24):2261-2269. doi: 10.2106/JBJS.21.00027. PMID: 34644269.Level Of Evidence: Level II – therapeutic
Scientific Literature Review
Reviewed By: Andrea C. Batra, DPM
Residency Program: Highlands/Presbyterian St. Luke’s – Denver, CO
Podiatric Relevance: The authors developed a questionnaire as a screening tool for patients with penicillin allergy to determine whether cefazolin was suitable for their intra-operative antibiotic prophylaxis. Although research suggests that the cross-reactivity of penicillin and other beta-lactam antibiotics with different side chains may be less than the classically described 10 percent, the risk of reaction remains a question that often drives perioperative decision making. Despite the availability of second line antibiotics, their utilization can potentially impact perioperative infection rates, adverse reactions, and cost of care. The author’s hypothesis was that employing this algorithm for intraoperative antibiotic prophylaxis would lead to a decrease in the use of second-line therapy.
Methods: The authors prospectively evaluated 4,156 patients (2,078 protocol and 2,078 control) who underwent total knee and total hip arthroplasty that received cefazolin, vancomycin, or clindamycin as antibiotic prophylaxis. Preoperatively, patients were educated by nursing about the low incidence of penicillin cross-reactivities and patients were subsequently asked to complete a questionnaire that helped staff to identify the presence and severity of allergies. Patients deemed low-risk received cefazolin and high-risk patients received vancomycin or clindamycin intraoperatively and immediately postoperatively.
Results: Three hundred fifty-seven patients (17.2 percent) in the protocol group self-reported a penicillin allergy which was compared with 310 patients (14.9 percent) in the control group who had a penicillin allergy in their medical history. The number of patients who received second-line antibiotic therapy (vancomycin or clindamycin) was significantly lower in the treatment group (5.7 percent) versus the protocol group (15.2 percent). Three of 239 patients (1.3 percent) in the low-risk protocol group experienced mild skin reaction to cefazolin during the study. There were no statistically significant differences in the rates of superficial, deep, or Clostridium difficile infections between the groups.
Conclusions: The authors concluded that their screening questionnaire allowed two-thirds of the patients with a self-reported penicillin allergy to safely receive cefazolin in the perioperative period without the need for further testing. This article describes the high cost burden of allergy testing, but does not evaluate the differences in cost between first and second-line antibiotic prophylaxis intraoperatively. Although it discusses possible differences in rates of postoperative infections between first and second-line therapy, their results suggest that there was no statistically significant difference in these sequelae in their study population. Overall, the questionnaire is a tool to facilitate an informed discussion with patients about their susceptibility to adverse reactions which may also help reduce intraoperative decision making for surgeons.