Optimizing perioperative antibiotic prophylaxis: a prospective cohort study on cefazolin utilization in surgical...

Penicillin allergy labels frequently lead to second-line antibiotics for surgical prophylaxis, due to concerns for cross-reactivity. This has led to increased patient morbidity, prolonged hospitalization, and increased healthcare costs. The most common perioperative cephalosporin, cefazolin, has unique R groups, the main antigenic portion of penicillin, which makes it safe to use in type 1 hypersensitivity penicillin allergy. We evaluated the effect of education on the incidence of the following: cefazolin usage in penicillin allergy labelled patients, allergic reactions, and surgical site infections.

As a prospective study with historical controls, perioperative clinicians were educated on the natural history of penicillin allergy, cross-reactivity with cephalosporins, and allergic reaction management. A questionnaire-based algorithm was provided as a guide for cefazolin use in penicillin allergy labelled patients. Chart reviews were conducted before and after educational interventions to assess cefazolin utilization and associated outcomes. 574 patients were included in the study (236 and 338 in the retrospective and prospective cohorts respectively). Participants were non-pregnant adults (≥ 18 years) with penicillin allergy labels undergoing surgery. Data analysis employed the Wilcoxon rank-sum and chi-square tests accordingly to compare the following variables: cefazolin use, administration of epinephrine for the treatment of allergy, and surgical site infections within 30 days of surgery. The primary outcome was to assess cefazolin utilization, with a secondary outcome comparing surgical site infections in first line versus second-line antibiotic administration.

Patients with penicillin allergy labels having surgery where cefazolin was indicated for antibiotic prophylaxis were included. Concurrent antibiotic therapy or requiring alternative prophylaxis meant exclusion. Cefazolin administration significantly increased from 38% to 58% during the study period (89/236 vs. 196/338, p < 0.001). There was no evidence of allergic reactions to cefazolin amongst the patients. Documented use of epinephrine was accounted for by non-allergic indications. There was no significant difference in surgical site infection between the control and intervention group respectively (3.2% vs. 5.9%, p = 0.23).

Antibiotic stewardship based on consensus guidelines led to a significant increase in cefazolin usage in patients with penicillin allergy labels. Employing this strategy has the potential to enhance patient safety, reduce surgical site infections, and mitigate healthcare costs.