Intracameral Cefuroxime Use in Cataract Surgery After Penicillin Allergy Reclassification

Among patients who have a penicillin allergy label (a history of any reaction to penicillin in their medical records), many cataract surgeries are performed yearly. Less than 1% of these patients have a true allergy to penicillin. The evidence supports limited concern regarding cephalosporin cross-reactivity; however, the guidance for surgeons regarding antibiotic selection in these patients remains unclear.

To examine rates of perioperative antibiotic selection after penicillin allergy label reclassification vs before reclassification.

Quality improvement study including 1905 patients identified with a penicillin allergy label undergoing cataract surgery between May 30, 2020, and May 30, 2025, at a large tertiary eye care center in the US. This analysis was conducted from June 2025 to December 2025.

Policy intervention for surgeons performing cataract surgery that featured enhanced pharmacy collaboration and guidance, suppression of automated electronic medical record alerts for cephalosporin cross-reactivity, and reclassification of the allergy in the medical record. The policy intervention date was set as November 30, 2022.

Patient receipt of intracameral antibiotics (1.0 mg/0.1 mL of cefuroxime or 0.5 mg/0.1 mL of moxifloxacin), topical antibiotics (eg, erythromycin or moxifloxacin), or no prophylaxis. Perioperative antibiotic selection rates were measured for all patients undergoing cataract surgery.

Among the 1905 patients with a penicillin allergy label in their medical record, 3077 cataract surgeries (some patients underwent >1 cataract surgery) were performed by 51 surgeons. In an unadjusted time series analysis, the mean rate of cefuroxime use was 80.0% (95% CI, 74.5%-84.7%) after the policy intervention date, which was far above the expected use rate of 3.3% (95% CI, 2.0%-4.4%) (P = .001). After adjustment, the mean rate of cefuroxime use was 71% (95% CI, 62%-79%) after the policy intervention date compared with a mean rate of 2% (95% CI, 1%-3%) before the intervention. The adjusted odds ratio was 0.37 (95% CI, 0.27-0.52; P < .001) for cefuroxime use after the policy intervention date in patients with high-risk allergies (such as a history of anaphylaxis or angioedema) noted in the medical record and prior to review by a pharmacist.

Evidence-based antibiotic selection policies for patients with a penicillin allergy label may enhance appropriate use of intracameral cefuroxime in cataract surgery. The rapid increase in cefuroxime use after the policy intervention date suggests surgeons may benefit from education and pharmacy support.