Cefazolin versus Alternative Antibiotics for Surgical Prophylaxis in Children With a Reported Penicillin Allergy

Cefazolin is the antibiotic of choice for prevention of surgical site infections for many pediatric surgical procedures. In patients with a reported penicillin allergy, cefazolin is often replaced with vancomycin or clindamycin. Outcomes may be worse when alternatives are used.

We performed a retrospective review among children (aged 0-18 y) who underwent surgical procedures (orthopedic, cardiac, neurosurgical, or plastic surgery) where cefazolin was indicated for surgical prophylaxis to determine the risk of developing a new drug allergy when cefazolin was administered preoperatively compared to vancomycin or clindamycin. Allergies occurring after the preincision antibiotic dose was given and up to 7 d after surgery were included.

A total of 46,418 patients were included; 89.6% received cefazolin. Seven (0.02%) patients had an adverse reaction to cefazolin; none had a prior history of penicillin allergy. Compared to cefazolin, adverse reactions were 7 times more likely (95% confidence interval 2-22.3) with clindamycin and 56.8 times more likely (95% confidence interval 16.3-181.7) with vancomycin.

Cefazolin drug reactions in children are rare, while reactions to alternatives are more common. We suggest cefazolin should be administered to all children preoperatively, when indicated, regardless of allergy unless the allergy is to cefazolin itself.