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Penicillin skin testing in cardiac surgery
David J Cook1, David W Barbara1, Karen E Singh2
1Department of Anesthesiology, College of Medicine, Mayo Clinic, Rochester, Minn.
Background:
Penicillin is the most commonly reported allergy in cardiac surgical patients and a history of penicillin allergy frequently results in the use of vancomycin for antibiotic prophylaxis. However, clinical history is unreliable and true allergy is rare. Penicillin allergy testing has the potential to reduce vancomycin use and indirectly the potential for selection of vancomycin-resistant organisms, a national priority.
Methods:
After the publication of the 2007 Society of Thoracic Surgeons practice guideline report, we initiated a penicillin allergy testing service for cardiac surgical patients in 2009. We sought to determine the true incidence of penicillin allergy in the tested population, whether testing availability reduced vancomycin use in those tested, and if vancomycin use was reduced in the entire cardiac surgical population as a whole.
Results:
A total of 276 patients were skin tested for allergy to penicillin or cephalosporin. Testing recommended no penicillin use in 13.8% of those tested giving a true penicillin allergy incidence of 0.9%. Only 24 of the 276 patients tested (9%) received vancomycin. However, given the small percentage of the total population that underwent allergy testing, the overall use of vancomycin in the cardiac surgery practice was not reduced in the posttesting period.
Conclusions:
The true rate of contraindication to penicillin in a cardiac surgical population is very low. Penicillin allergy testing can reduce vancomycin use in the tested population, but better means of conducting the testing and making the results available are necessary to reduce unnecessary vancomycin use in a broader cardiac surgical population.
Insights
Penicillin allergy testing in cardiac surgery patients revealed a true allergy incidence of only 0.9%. While testing reduced vancomycin use in those tested, overall practice reduction requires broader implementation.
Area of Science:
- Cardiology
- Infectious Diseases
- Allergy Immunology
Background:
- Penicillin allergy is frequently reported in cardiac surgery patients, often leading to vancomycin use.
- Clinical history of penicillin allergy is unreliable, with true allergies being rare.
- Reducing vancomycin use is a national priority to combat vancomycin-resistant organisms.
Purpose of the Study:
- To determine the true incidence of penicillin allergy in cardiac surgical patients.
- To assess if penicillin allergy testing reduces vancomycin use in tested individuals.
- To evaluate the impact of testing on overall vancomycin use in the cardiac surgery population.
Main Methods:
- A penicillin allergy testing service was established for cardiac surgical patients in 2009.
- 276 patients underwent skin testing for penicillin or cephalosporin allergy.
- Outcomes measured included true allergy incidence and vancomycin utilization rates.
Main Results:
- The true incidence of penicillin allergy was found to be 0.9% (13.8% recommended no penicillin use).
- Only 9% of tested patients received vancomycin.
- Overall vancomycin use in the cardiac surgery practice did not decrease due to limited testing reach.
Conclusions:
- The actual contraindication rate for penicillin in cardiac surgery patients is very low.
- Penicillin allergy testing effectively reduces vancomycin use among tested patients.
- Wider implementation and accessibility of testing are needed to decrease unnecessary vancomycin use broadly.
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