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A Simple Algorithmic Approach Allows the Safe Use of Cephalosporin in "Penicillin-Allergic" Patients without the Need
Graham S Goh1, Noam Shohat1,2, Matthew S Austin1
1Rothman Orthopaedic Institute, Thomas Jefferson University, Philadelphia, Pennsylvania.
Background:
Patients who report a penicillin allergy are often given second-line antibiotic prophylaxis during total joint arthroplasty (TJA), with only a minority of patients undergoing additional consultations and allergy testing. In an effort to increase the use of cephalosporin prophylaxis in TJA, the present study aimed to assess the effectiveness of a simple, protocol-driven penicillin allergy screening program without the need for additional work-up.
Methods:
Following implementation of a questionnaire-based screening protocol in May 2019, all patients scheduled for primary TJA were risk-stratified into low or high-risk categories. The low-risk cohort received cefazolin, and the high-risk cohort received non-cefazolin antibiotics. Patients were monitored prospectively, and data on antibiotic usage and adverse outcomes were documented. The protocol group (n = 2,078) was propensity score matched 1:1 with a control group that included patients who underwent TJA in the same institution prior to implementation of the protocol. The primary end point was the efficacy of the protocol in reducing unnecessary use of non-cephalosporin antibiotics for prophylaxis. Secondary outcomes included the rate of surgical site infections and allergic reactions to the administered antibiotic.
Results:
A total of 357 patients (17.2%) reported a penicillin allergy in the protocol group compared with 310 patients (14.9%) with a recorded allergy in the control group (p = 0.052). The number of patients who received non-cephalosporin antibiotics was significantly lower in the protocol group (5.7% compared with 15.2% in the control group; p < 0.001), whereas there was no difference in the rate of total allergic reactions (0.8% compared with 0.7%, respectively; p = 0.857). Of the 239 low-risk patients (66.9%) in the protocol group, only 3 (1.3%) experienced a mild cutaneous reaction following cefazolin administration. There were no differences in the rates of superficial wound, deep periprosthetic, or Clostridioides difficile infections between the protocol and control groups.
Conclusions:
A simple screening protocol allowed two-thirds of patients with a self-reported allergy to receive cefazolin without the need for additional consultations or testing. We believe this protocol can be safely implemented to increase the rate of cefazolin usage without a corresponding increase in the number of allergic reactions.
Level Of Evidence:
Therapeutic Level II. See Instructions for Authors for a complete description of levels of evidence.
Insights
A simple screening protocol safely increased cefazolin use in total joint arthroplasty (TJA) patients with penicillin allergies. This reduced unnecessary non-cephalosporin antibiotics without increasing allergic reactions.
Area of Science:
- Orthopedic Surgery
- Infectious Disease
- Clinical Pharmacy
Background:
- Patients reporting penicillin allergy often receive second-line antibiotics for total joint arthroplasty (TJA) prophylaxis.
- Few patients undergo allergy testing, leading to potential overuse of broader-spectrum antibiotics.
Purpose of the Study:
- To evaluate a protocol-driven penicillin allergy screening program for TJA.
- To increase the appropriate use of cefazolin prophylaxis.
Main Methods:
- Implemented a questionnaire-based screening protocol stratifying patients into low and high-risk categories.
- Low-risk patients received cefazolin; high-risk patients received non-cefazolin antibiotics.
- Propensity score matching compared the protocol group (n=2,078) with a pre-protocol control group.
Main Results:
- Significantly reduced non-cephalosporin antibiotic use (5.7% vs. 15.2%; p < 0.001).
- No significant difference in total allergic reactions (0.8% vs. 0.7%; p = 0.857).
- 1.3% of low-risk patients experienced mild cutaneous reactions to cefazolin.
Conclusions:
- A simple screening protocol enables appropriate cefazolin use in TJA patients with self-reported penicillin allergies.
- The protocol can be safely implemented to increase cefazolin usage without increasing adverse reactions.
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