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Published on: February 1, 2018
Non-β-Lactam Antibiotic Use, β-Lactam Allergy, and Surgical Site Infections
Prateek Agarwal1, Rohit Prem Kumar1, Louise-Marie Oleksiuk2
1Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania.
Importance:
Surgical site infections (SSIs) pose significant health and economic burdens. β-lactams are the recommended prophylactic antibiotics for most surgical procedures; however, the association of non-β-lactam antibiotics with SSI incidence is controversial.
Objective:
To evaluate the association between reported β-lactam allergy status, β-lactam antibiotics, and SSIs across various surgical specialties.
Design, Setting, And Participants:
This was a retrospective cohort study of a prospectively recorded database. The setting was a quaternary health center. Included in the study were patients who underwent surgery from January 2021 to February 2024.
Exposures:
Study exposures included antibiotic choice and reported β-lactam allergy, with covariates including demographics, comorbidities, and procedure details.
Main Outcomes And Measures:
The primary study outcome was 30- to 90-day SSI incidence.
Results:
The study included 49 279 procedures across 10 specialties, with a total of 41 100 patients (mean [SD] age, 61.0 [15.9] years; range, 13-103 years; 21 237 male [51.7%]). Procedures with non-β-lactam antibiotic use had a higher incidence of SSI than procedures with β-lactam antibiotic use (2.2% vs 1.3%; risk ratio [RR], 1.69; 95% CI, 1.28-2.01; P < .001). Procedures in patients with reported β-lactam allergy had a higher incidence of SSI (1.8% vs 1.3%; RR, 1.38; 95% CI, 1.15-1.64; P = .003). These associations were present in logistic regression as well. However, on controlling for covariates and β-lactam allergy, non-β-lactam antibiotic use remained significantly associated with higher SSI incidence (odds ratio [OR], 1.33; 95% CI, 1.00-1.74; P = .04), whereas the association between β-lactam allergy and SSI incidence became nonsignificant (OR, 1.21; 95% CI, 0.97-1.49; P = .09). In subspecialty analysis, only orthopedic surgery retained a significant association between non-β-lactam use and increased SSI (OR, 3.01; 95% CI, 1.41-6.01; P = .003).
Conclusions And Relevance:
This cohort study found that β-lactam prophylaxis was associated with significantly lower SSI rates than non-β-lactam agents, and a reported β-lactam allergy did not independently predict infection risk. Implementation of an allergy-focused stewardship guideline was associated with a marked reduction in non-β-lactam use, underscoring the importance of precise allergy assessment to avoid unnecessary alternative prophylaxis.
Insights
Surgical site infections (SSIs) were higher with non-β-lactam antibiotics compared to β-lactams. Reported β-lactam allergy did not independently increase SSI risk, highlighting the need for accurate allergy assessment.
Area of Science:
- Infectious Disease Epidemiology
- Surgical Infection Prevention
- Antibiotic Stewardship
Background:
- Surgical site infections (SSIs) represent a significant global health and economic challenge.
- While β-lactam antibiotics are standard for surgical prophylaxis, their superiority over non-β-lactam agents is debated, particularly in patients with reported β-lactam allergies.
Purpose of the Study:
- To investigate the relationship between patient-reported β-lactam allergy status, antibiotic choice (β-lactam vs. non-β-lactam), and the incidence of SSIs.
- To analyze these associations across diverse surgical specialties.
Main Methods:
- Retrospective cohort study utilizing a prospectively recorded database from a quaternary health center.
- Inclusion of 49,279 procedures across 10 surgical specialties performed between January 2021 and February 2024.
- Analysis of antibiotic prophylaxis (β-lactam vs. non-β-lactam), reported β-lactam allergy, and 30- to 90-day SSI incidence, controlling for patient demographics and comorbidities.
Main Results:
- Procedures using non-β-lactam antibiotics exhibited a higher SSI incidence (2.2%) compared to those using β-lactams (1.3%; RR, 1.69).
- Patients with a reported β-lactam allergy also showed a higher SSI incidence (1.8% vs. 1.3%; RR, 1.38).
- After adjusting for covariates and β-lactam allergy, non-β-lactam use remained associated with increased SSI risk (OR, 1.33), while the association with β-lactam allergy became non-significant (OR, 1.21). Orthopedic surgery showed a significant association between non-β-lactam use and SSI (OR, 3.01).
Conclusions:
- β-lactam prophylaxis is associated with significantly lower SSI rates compared to non-β-lactam alternatives.
- A reported β-lactam allergy does not appear to be an independent predictor of SSI risk.
- Precise allergy assessment is crucial to avoid unnecessary use of alternative antibiotics and optimize surgical infection prevention strategies.
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