Use of clindamycin as an alternative antibiotic prophylaxis

Clindamycin serves as an alternative surgical prophylactic antibiotic in patients with penicillin (PCN) or cephalosporin allergy labels. In the previous reports, the use of clindamycin was associated with higher incidences of surgical site infections (SSIs). We aimed to determine the characteristics of PCN or cephalosporin allergic reactions to stratify patient's risk and indicate subsequent management; leading to de-labeling of PCN or cephalosporin allergy.

We conducted a prospective cohort study of patients receiving clindamycin as surgical antibiotic prophylaxis from September 2021 to March 2022. Data were collected from electronic medical records; included demographic data, antibiotic allergy labels, allergic reaction, and allergy testing.

Clindamycin was administered in 445 patients who underwent 451 operations. Among these patients, 53.0% (n = 236) were female with a median age of 15 years (range; 0.5-57.0 years). PCN and cephalosporin allergies were labelled in 83.8% (n = 373) and 25.6% (n = 114) patients, respectively; 11.4% (n = 51) of patients were allergic to both classes of the antibiotics. There were 191 (51.2%) and 73 (64.0%) possible hypersensitivity reactions (HSRs) in PCN and cephalosporin groups, respectively. The most common reactions were rash (PCN: n = 99, 26.5%; cephalosporin: n = 35, 30.7%), and hives (PCN: n = 71, 19.0%; cephalosporin: n = 24, 21.1%). Severe reactions included angioedema (PCN: n = 7, 1.9%; cephalosporin: n = 5, 4.4%), anaphylaxis (PCN: n = 8, 2.1%; cephalosporin: n = 7, 6.1%), bronchospasm (cephalosporin: n = 1, 0.9%), airway involvement (PCN: n = 1, 0.3%; cephalosporin: n = 1, 0.9%), serum sickness (PCN: n = 1, 0.3%), blisters (PCN: n = 1, 0.3%), and drug reaction with eosinophilia and systemic symptoms (DRESS) (PCN: n = 1, 0.3%). Low-risk history of allergy included gastrointestinal side effects (PCN: n = 9, 2.4%; cephalosporin: n = 3, 2.7%), positive family history (PCN: n = 7, 1.9%; cephalosporin: n = 1, 0.9%), and remote history of allergy (PCN: n = 2, 0.5%). There were 201 (53.9%) and 53 (46.5%) unknown reactions in PCN and cephalosporin groups, respectively. In the overall cohort, 3 patients (0.7%) were skin tested for drug allergy (PCN: n = 2, 0.5%; cephalosporin: n = 2, 1.8%).

Clindamycin was largely administered in patients with non-severe HSRs, low-risk history or unknown reactions to PCN or cephalosporin, whom cefazolin could have been administered safely. Obtaining a detailed history of antibiotic allergy, allergy testing and/or direct oral challenge can de-label unsubstantiated PCN or cephalosporin allergy and ultimately reduce the incidence of SSIs by optimizing the rate of more effective antibiotic administration.