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Tsoulis MW, Hsu Blatman KS, Chow VW, Stewart KO, Wang R, Reigh EL. A nurse-driven penicillin allergy risk score in the preoperative setting was associated with increased cefazolin use perioperatively. J Clin Anesth 2024; 95:111443. [PMID: 38484506 DOI: 10.1016/j.jclinane.2024.111443] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2023] [Revised: 02/19/2024] [Accepted: 03/07/2024] [Indexed: 04/29/2024]
Abstract
STUDY OBJECTIVE To characterize and assess the effects of a preoperative, nurse-driven penicillin allergy risk stratification tool on rates of perioperative cefazolin and second-line antibiotic use. DESIGN Quasi-experimental quality improvement study of penicillin-allergic surgical patients undergoing procedures for which cefazolin is indicated. SETTING Outpatient Perioperative Care Clinic (PCC) for preoperative surgical patients at a tertiary care center. PATIENTS 670 and 1371 adult penicillin-allergic PCC attendants and non-attendants, respectively. INTERVENTION A paper penicillin allergy risk stratification questionnaire was administered during the PCC visit. Nurses were educated on its use. MEASUREMENTS Antibiotic (cefazolin, clindamycin, vancomycin) use rates in the 24 months before and 17 months after intervention implementation in November 2020 (November 2018 - April 2022) were assessed in penicillin-allergic PCC attendants with statistical process control charts. Multivariable logistic regression assessed antibiotic use rates pre- and post-intervention adjusting for age, sex, surgical specialty and penicillin allergy history severity. Similar analyses were done in penicillin-allergic PCC non-attendants. MAIN RESULTS Of 670 penicillin-allergic PCC attendants, 451 (median [IQR] age, 66 (Sousa-Pinto et al., 2021 [14])) were analyzed pre-intervention and 219 (median [IQR] age, 66 (Mine et al., 1970 [13])) post-intervention. One month after implementation, process measures demonstrated an upward shift in cefazolin use for PCC attendants versus no shift or other special cause variation for PCC non-attendants. There were increased odds of cefazolin use (aOR 1.67, 95% CI [1.09-2.57], P = 0.019), decreased odds of clindamycin use (aOR 0.61, 95% CI [0.42-0.89], P = 0.010) and decreased odds of vancomycin use (aOR 0.56, 95% CI [0.35-0.88], P = 0.013) in PCC attendants post-intervention. This effect did not occur in PCC non-attendants. There was no increase in perioperative anaphylaxis post-intervention. CONCLUSIONS A simple penicillin allergy risk stratification tool implemented in the preoperative setting was associated with increased use of cefazolin and decreased rates of second-line agents post implementation.
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Affiliation(s)
- Michael W Tsoulis
- Department of Medicine, Dartmouth Hitchcock Medical Center, 1 Medical Center Drive Lebanon, NH 03756, USA
| | - Karen S Hsu Blatman
- Department of Medicine, Dartmouth Hitchcock Medical Center, 1 Medical Center Drive Lebanon, NH 03756, USA; Section of Allergy and Clinical Immunology, Dartmouth Hitchcock Medical Center, 1 Medical Center Drive, Lebanon, NH 03756, USA; Geisel School of Medicine at Dartmouth, 1 Rope Ferry Rd, Hanover, NH 03755, USA
| | - Vinca W Chow
- Geisel School of Medicine at Dartmouth, 1 Rope Ferry Rd, Hanover, NH 03755, USA; Department of Anesthesiology, Dartmouth Hitchcock Medical Center, 1 Medical Center Drive, Lebanon, NH 03756, USA
| | - Kathleen O Stewart
- The Dartmouth Institute for Health Policy and Clinical Practice, 1 Medical Center Drive, Lebanon, NH 03766, USA; Collaborative Healthcare-associated Infection Prevention Program, Dartmouth Hitchcock Medical Center, 1 Medical Center Drive, Lebanon, NH 03756, USA
| | - Rebecca Wang
- Department of Medicine, Dartmouth Hitchcock Medical Center, 1 Medical Center Drive Lebanon, NH 03756, USA; Geisel School of Medicine at Dartmouth, 1 Rope Ferry Rd, Hanover, NH 03755, USA; The Dartmouth Institute for Health Policy and Clinical Practice, 1 Medical Center Drive, Lebanon, NH 03766, USA; Section of Infectious Disease and International Health, Dartmouth Hitchcock Medical Center, 1 Medical Center Drive, Lebanon, NH 03756, USA
| | - Erin L Reigh
- Department of Medicine, Dartmouth Hitchcock Medical Center, 1 Medical Center Drive Lebanon, NH 03756, USA; Section of Allergy and Clinical Immunology, Dartmouth Hitchcock Medical Center, 1 Medical Center Drive, Lebanon, NH 03756, USA; Geisel School of Medicine at Dartmouth, 1 Rope Ferry Rd, Hanover, NH 03755, USA.
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Ali SB, Hughes T, Smith A. Penicillin or cephalosporin antibiotic allergy label: Influence on length of stay and hospital readmission. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. GLOBAL 2024; 3:100272. [PMID: 38817345 PMCID: PMC11137559 DOI: 10.1016/j.jacig.2024.100272] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/07/2023] [Revised: 02/04/2024] [Accepted: 02/15/2024] [Indexed: 06/01/2024]
Abstract
Background A penicillin or cephalosporin antibiotic (PCA) allergy label (PCAAL) has negative implications for both the patient and health care alike. Objective A retrospective study was undertaken to evaluate the influence of a PCAAL on length of stay (LOS) and hospital readmissions. Methods Over 4 weeks, inpatients with a PCAAL who were referred to the allergy service or opportunistically reviewed were grouped in the categories delabeled (group 1a) or advice not followed (ie, label carriage) (group 1b). Comparator groups without a PCAAL were identified, those either on a PCA (the PCA group [group 2]) or on a non-PCA (the non-PCA group [group 3]). Results The study population comprised 77 patients as follows: group 1a (n = 19), group 1b (n = 6), group 2 (n = 36), and group 3 (n = 16). Those in group 1a were significantly older (median age 78 years) than those in group 1b (median age 53 years [P = .013]) or group 3 (median age 59 years [P = .013]).There was a trend toward lower LOS in group 1a (10 days) than in group 1b (11.5 days [P = not significant]). Group 2 had a significantly lower LOS (6 days) than either both group 1a (10 days [P = .043]) or group 3 (15 days [P = .002]). Group 3 had the highest rate of patients readmitted within 30 days (n = 5 [71.4%]). Conclusion A PCAAL carries influence on both LOS and readmissions, thus identifying the prompt need for allergy review to provide specific recommendations: delabeling and transition to an appropriate antibiotic. The significantly older group of those with a PCAAL who received a PCA after delabeling (ie, a 20-year age difference) may also be a signal that more elderly and comorbid patients benefit from this intervention the most.
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Affiliation(s)
- Syed B. Ali
- Department of Clinical Immunology and Allergy, Flinders Medical Centre, Bedford Park, Australia
- School of Medicine, Flinders University, Bedford Park, Australia
| | - Tiffany Hughes
- Department of Clinical Immunology and Allergy, Flinders Medical Centre, Bedford Park, Australia
- School of Medicine, Flinders University, Bedford Park, Australia
| | - Anthony Smith
- Department of Clinical Immunology and Allergy, Flinders Medical Centre, Bedford Park, Australia
- School of Medicine, Flinders University, Bedford Park, Australia
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Zoller M, Weber A, Mehringer L. [Penicillin allergy-Truth or duty?]. DIE ANAESTHESIOLOGIE 2024; 73:436-443. [PMID: 38904675 DOI: 10.1007/s00101-024-01425-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 05/28/2024] [Indexed: 06/22/2024]
Abstract
The beta-lactam antibiotics are some of the safest and best-tolerated antibiotic agents; however, many patients have reported allergies against penicillin. All beta-lactam antibiotics are only restrictively prescribed for these patients and alternative antibiotics are increasingly given, which carries the risk of negative clinical results and socioeconomic sequelae; however, over 95% of patients who reported an allergy to penicillin show a negative result in the allergy tests for penicillin and this antibiotic can safely be prescribed. The use of sensitive and specific instruments for identification of false penicillin allergies should be an important topic within the framework of antibiotic stewardship. Anesthesists can play a central role in the reduction of the enormous individual and public health burden associated with the classification of penicillin allergy by taking an appropriate medical history and a risk stratification for the identification of patients with a penicillin allergy. This overview article presents a possible delabelling algorithm within the framework of the clarification of a beta-lactam antibiotic allergy. The focus is on a structured allergy anamnesis using the penicillin allergy, five or fewer years ago, anaphylaxis/angioedema, severe cutaneous adverse reaction (SCAR) and treatment required for allergy episode (PEN-FAST) score.
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Affiliation(s)
- Michael Zoller
- Klinik für Anästhesiologie, LMU Klinikum der Universität München, Marchioninistr. 15, 81377, München, Deutschland.
| | | | - Laurenz Mehringer
- Klinik für Anästhesiologie, LMU Klinikum der Universität München, Marchioninistr. 15, 81377, München, Deutschland
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Doğan CZ, Yalçın N, Cennet Ö, Metan G, Demirkan K, Yorgancı K. Optimization of appropriate antimicrobial prophylaxis in general surgery: a prospective cohort study. Eur J Med Res 2024; 29:340. [PMID: 38890673 PMCID: PMC11186073 DOI: 10.1186/s40001-024-01938-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2024] [Accepted: 06/14/2024] [Indexed: 06/20/2024] Open
Abstract
BACKGROUND Surgical site infections (SSI) are characterized by infections occurring in the surgical incision site, organ or cavity in the postoperative period. Adherence to surgical antimicrobial prophylaxis (SAP) is paramount in mitigating the occurrence of SSIs. In this study, we aimed to evaluate the appropriateness of SAP use in patients undergoing surgical procedures in the field of general surgery according to the American Society of Health-System Pharmacists (ASHP) guideline and to determine the difference between the pre-training period (pre-TP) and the post-training period (post-TP) organized according to this guideline. METHODS It is a single-center prospective study conducted in general surgery wards between January 2022 and May 2023, with 404 patients pre-TP and 406 patients post-TP. RESULTS Cefazolin emerged as the predominant agent for SAP, favored in 86.8% (703/810) of cases. Appropriate cefazolin dosage increased significantly from 41% (129 patients) in pre-TP to 92.6% (276 patients) in post-TP (p < 0.001), along with a rise in adherence to recommended timing of administration from 42.2% (133 patients) to 62.8% (187 patients) (p < 0.001). The proportion of patients receiving antibiotics during hospitalization in the ward postoperatively decreased post-TP (21-14.3%; p = 0.012), as did antibiotic prescription at discharge (16.8-10.3%; p = 0.008). The incidence of SSI showed a slight increase from 9.9% in pre-TP to 13.3% in post-TP (p = 0.131). CONCLUSIONS Routine training sessions for surgeons emerged as crucial strategies to optimize patient care and enhance SAP compliance rates, particularly given the burden of clinical responsibilities faced by surgical teams.
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Affiliation(s)
- Cansu Zeynep Doğan
- Department of Clinical Pharmacy, Faculty of Pharmacy, Hacettepe University, 06230, Ankara, Turkey
| | - Nadir Yalçın
- Department of Clinical Pharmacy, Faculty of Pharmacy, Hacettepe University, 06230, Ankara, Turkey.
| | - Ömer Cennet
- Department of General Surgery, Faculty of Medicine, Hacettepe University, 06230, Ankara, Turkey
| | - Gökhan Metan
- Department of Infectious Diseases and Clinical Microbiology, Faculty of Medicine, Hacettepe University, 06230, Ankara, Turkey
| | - Kutay Demirkan
- Department of Clinical Pharmacy, Faculty of Pharmacy, Hacettepe University, 06230, Ankara, Turkey
| | - Kaya Yorgancı
- Department of General Surgery, Faculty of Medicine, Hacettepe University, 06230, Ankara, Turkey
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5
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Jones NK, Tom B, Simillis C, Bennet J, Gourgiotis S, Griffin J, Blaza H, Nasser S, Baker S, Gouliouris T. Impact of penicillin allergy labels on surgical site infections in a large UK cohort of gastrointestinal surgery patients. JAC Antimicrob Resist 2024; 6:dlae022. [PMID: 38372001 PMCID: PMC10873540 DOI: 10.1093/jacamr/dlae022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2023] [Accepted: 01/26/2024] [Indexed: 02/20/2024] Open
Abstract
Objectives Studies in the USA, Canada and France have reported higher surgical site infection (SSI) risk in patients with a penicillin allergy label (PAL). Here, we investigate the association between PALs and SSI in the UK, a country with distinct epidemiology of infecting pathogens and range of antimicrobial regimens in routine use. Methods Electronic health records and national SSI surveillance data were collated for a retrospective cohort of gastrointestinal surgery patients at Cambridge University Hospitals NHS Foundation Trust from 1 January 2015 to 31 December 2021. Univariable and multivariable logistic regression were used to examine the effects of PALs and the use of non-β-lactam-based prophylaxis on likelihood of SSI, 30 day post-operative mortality, 7 day post-operative acute kidney injury and 60 day post-operative infection/colonization with antimicrobial-resistant bacteria or Clostridioides difficile. Results Our data comprised 3644 patients and 4085 operations; 461 were undertaken in the presence of PALs (11.3%). SSI was detected after 435/4085 (10.7%) operations. Neither the presence of PALs, nor the use of non-β-lactam-based prophylaxis were found to be associated with SSI: adjusted OR (aOR) 0.90 (95% CI 0.65-1.25) and 1.20 (0.88-1.62), respectively. PALs were independently associated with increased odds of newly identified MRSA infection/colonization in the 60 days after surgery: aOR 2.71 (95% CI 1.13-6.49). Negative association was observed for newly identified infection/colonization with third-generation cephalosporin-resistant Gram-negative bacteria: aOR 0.38 (95% CI 0.16-0.89). Conclusions No evidence was found for an association between PALs and the likelihood of SSI in this large UK cohort, suggesting significant international variation in the impact of PALs on surgical patients.
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Affiliation(s)
- Nick K Jones
- Department of Medicine, University of Cambridge, Cambridge, UK
- Cambridge Clinical Microbiology and Public Health Laboratory, Cambridge University Hospitals NHS Foundation Trust, Addenbrooke’s Hospital, Hills Road, Cambridge CB2 0QQ, UK
- Department of Infectious Diseases, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Brian Tom
- MRC Biostatistics Unit, Cambridge University, Cambridge, UK
| | - Constantinos Simillis
- Cambridge Colorectal Unit, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
- Department of Surgery, University of Cambridge, Cambridge, UK
| | - John Bennet
- Department of General Surgery, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Stavros Gourgiotis
- Department of General Surgery, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Jo Griffin
- Department of Infection, Prevention and Control, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Helen Blaza
- Department of Infection, Prevention and Control, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Shuaib Nasser
- Department of Allergy, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Stephen Baker
- Department of Medicine, University of Cambridge, Cambridge, UK
| | - Theodore Gouliouris
- Department of Medicine, University of Cambridge, Cambridge, UK
- Cambridge Clinical Microbiology and Public Health Laboratory, Cambridge University Hospitals NHS Foundation Trust, Addenbrooke’s Hospital, Hills Road, Cambridge CB2 0QQ, UK
- Department of Infectious Diseases, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
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6
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Jones NK, Morris B, Santos R, Nasser S, Gouliouris T. Characterizing Antibiotic Allergy Labels in a Large UK Hospital Population to Inform Antimicrobial Stewardship and Delabeling Assessment Strategy. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. IN PRACTICE 2023; 11:2180-2189.e4. [PMID: 37088372 DOI: 10.1016/j.jaip.2023.03.056] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/24/2023] [Revised: 03/23/2023] [Accepted: 03/29/2023] [Indexed: 04/25/2023]
Abstract
BACKGROUND Antibiotic allergy labels are important barriers to treatment and antimicrobial stewardship, but their prevalence in UK hospitals is poorly described. OBJECTIVE To ascertain the prevalence and characteristics of antibiotic allergy labels in a large UK hospital setting and estimate the proportion of penicillin allergy labels for which point-of-care (POC) delabeling assessment would be appropriate. METHODS Electronic health records data were analyzed from all patients treated at Cambridge University Hospitals NHS Foundation Trust in 2019. Validated POC delabeling risk stratification criteria were retrospectively applied to penicillin allergy labels. RESULTS Recorded reactions to antibiotics were present in 11.8% of all patients (32,148 of 273,216), 16.3% of inpatients (13,874 of 85,230), and 9.7% of outpatients (18,274 of 187,986). Penicillins were the commonest reaction precipitant described (9.0% of patients; 24,646 of 273,216), followed by sulfonamides/trimethoprim (1.4%; 3869 of 273,216) and macrolides/lincosamides (1.3%; 3644 of 273,216). A total of 3.9% of inpatients had recorded reactions to >1 antibiotic class (3348 of 85,230). Cutaneous manifestations were the most commonly described reaction features (40.7% of labels; 15,821 of 38,902). Of 15,949 labels describing probable or possible penicillin "allergy" with sufficient detail to allow for the retrospective assessment of POC delabeling suitability, 1702 were deemed suitable for removal or downgrading of the label to "intolerance" without further investigation (10.7%), 11,887 were appropriate for POC assessment using an oral penicillin challenge (OPC) or OPC with prior bedside skin testing (74.5%), and 2360 were identified as unsuitable for any form of POC assessment (14.8%). CONCLUSIONS Antibiotic allergy labels are highly prevalent in a UK hospital setting. A large proportion of penicillin allergy labels may be suitable for POC delabeling assessment.
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Affiliation(s)
- Nick K Jones
- Cambridge Clinical Microbiology and Public Health Laboratory, Cambridge University Hospitals NHS Foundation Trust, Cambridge, United Kingdom; Department of Infectious Diseases, Cambridge University Hospitals NHS Foundation Trust, Cambridge, United Kingdom; Department of Medicine, University of Cambridge, Cambridge, United Kingdom.
| | - Bethan Morris
- Department of Medicine, University of Cambridge, Cambridge, United Kingdom
| | - Reem Santos
- Cambridge Clinical Microbiology and Public Health Laboratory, Cambridge University Hospitals NHS Foundation Trust, Cambridge, United Kingdom
| | - Shuaib Nasser
- Department of Allergy, Cambridge University Hospitals NHS Foundation Trust, Cambridge, United Kingdom
| | - Theodore Gouliouris
- Cambridge Clinical Microbiology and Public Health Laboratory, Cambridge University Hospitals NHS Foundation Trust, Cambridge, United Kingdom; Department of Infectious Diseases, Cambridge University Hospitals NHS Foundation Trust, Cambridge, United Kingdom; Department of Medicine, University of Cambridge, Cambridge, United Kingdom
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7
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Honkanen M, Sirkeoja S, Karppelin M, Eskelinen A, Syrjänen J. Effect of non-cephalosporin antibiotic prophylaxis on the risk of periprosthetic joint infection after total joint replacement surgery: a retrospective study with a 1-year follow-up. Infect Prev Pract 2023; 5:100285. [PMID: 37223241 PMCID: PMC10200839 DOI: 10.1016/j.infpip.2023.100285] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2022] [Accepted: 04/25/2023] [Indexed: 05/25/2023] Open
Abstract
Background Cephalosporins are recommended as first-line antibiotic prophylaxis in total joint replacement surgery. Studies have shown an increased risk for periprosthetic joint infection (PJI) when non-cephalosporin antibiotics have been used. This study examines the effect of non-cephalosporin antibiotic prophylaxis on the risk for PJI. Methods Patients with a primary hip or knee replacement performed from 2012 to 2020 were identified (27 220 joint replacements). The primary outcome was the occurrence of a PJI in a one-year follow-up. The association between perioperative antibiotic prophylaxis and the outcome was examined using logistic regression analysis. Discussion Cefuroxime was used as prophylaxis in 26,467 operations (97.2%), clindamycin in 654 (2.4%) and vancomycin in 72 (0.3%). The incidence of PJI was 0.86% (228/26,467) with cefuroxime and 0.80% (6/753) with other prophylactic antibiotics. There was no difference in the risk for PJI with different prophylactic antibiotics in the univariate (OR 1.06, 95% CI 0.47-2.39) or multivariable analysis (OR 1.02, 95% CI 0.45-2.30). Conclusion Non-cephalosporin antibiotic prophylaxis in primary total joint replacement surgery was not associated with an increased risk for PJI.
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Affiliation(s)
- Meeri Honkanen
- Department of Internal Medicine, Tampere University Hospital and Faculty of Medicine and Life Sciences, Tampere University, Finland
| | - Simo Sirkeoja
- Department of Internal Medicine, Tampere University Hospital and Faculty of Medicine and Life Sciences, Tampere University, Finland
| | - Matti Karppelin
- Department of Internal Medicine, Tampere University Hospital and Faculty of Medicine and Life Sciences, Tampere University, Finland
| | - Antti Eskelinen
- Coxa, Hospital for Joint Replacement, Tampere and Faculty of Medicine and Life Sciences, Tampere University, Finland
| | - Jaana Syrjänen
- Department of Internal Medicine, Tampere University Hospital and Faculty of Medicine and Life Sciences, Tampere University, Finland
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Calderwood MS, Anderson DJ, Bratzler DW, Dellinger EP, Garcia-Houchins S, Maragakis LL, Nyquist AC, Perkins KM, Preas MA, Saiman L, Schaffzin JK, Schweizer M, Yokoe DS, Kaye KS. Strategies to prevent surgical site infections in acute-care hospitals: 2022 Update. Infect Control Hosp Epidemiol 2023; 44:695-720. [PMID: 37137483 PMCID: PMC10867741 DOI: 10.1017/ice.2023.67] [Citation(s) in RCA: 42] [Impact Index Per Article: 42.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/05/2023]
Abstract
The intent of this document is to highlight practical recommendations in a concise format designed to assist acute-care hospitals in implementing and prioritizing their surgical-site infection (SSI) prevention efforts. This document updates the Strategies to Prevent Surgical Site Infections in Acute Care Hospitals published in 2014. This expert guidance document is sponsored by the Society for Healthcare Epidemiology of America (SHEA). It is the product of a collaborative effort led by SHEA, the Infectious Diseases Society of America (IDSA), the Association for Professionals in Infection Control and Epidemiology (APIC), the American Hospital Association (AHA), and The Joint Commission, with major contributions from representatives of a number of organizations and societies with content expertise.
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Affiliation(s)
| | - Deverick J. Anderson
- Duke Center for Antimicrobial Stewardship and Infection Prevention, Duke University School of Medicine, Durham, North Carolina, United States
| | - Dale W. Bratzler
- University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma, United States
| | | | | | - Lisa L. Maragakis
- Johns Hopkins School of Medicine, Baltimore, Maryland, United States
| | - Ann-Christine Nyquist
- Children’s Hospital Colorado, University of Colorado School of Medicine, Aurora, Colorado, United States
| | - Kiran M. Perkins
- Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia, United States
| | - Michael Anne Preas
- University of Maryland Medical System, Baltimore, Maryland, United States
| | - Lisa Saiman
- Columbia University Irving Medical Center and NewYork–Presbyterian Hospital, New York, New York, United States
| | - Joshua K. Schaffzin
- Children’s Hospital of Eastern Ontario, University of Ottawa, Ottawa, Ontario, Canada
| | - Marin Schweizer
- Center for Access and Delivery Research and Evaluation, Iowa City VA Health Care System, University of Iowa, Iowa City, Iowa
| | - Deborah S. Yokoe
- University of California-San Francisco, San Francisco, California, United States
| | - Keith S. Kaye
- Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey, United States
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Niu T, Bao X, Wei J, Shi Y, Ma W, Wang R. Impact of Penicillin Allergy-Based Alternative Antibiotics on the Risk of Postoperative Central Nervous System Infection: A Retrospective Cohort Study. World Neurosurg 2023; 171:e745-e751. [PMID: 36584894 DOI: 10.1016/j.wneu.2022.12.102] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2022] [Accepted: 12/23/2022] [Indexed: 12/28/2022]
Abstract
BACKGROUND Central nervous system (CNS) infection is one of the most serious complications after neurosurgery. This study aimed to analyze the effect of penicillin allergy (PA) and alternative prophylactic antibiotics on risk of postoperative CNS infection in patients undergoing neurosurgery. METHODS Data of patients who underwent neurosurgical procedures from January 2015 to December 2021 were analyzed retrospectively. Patients with PA were compared with patients without PA in a 1:1 ratio. A multivariate logistic regression model was used to examine whether PA was a risk factor for postoperative CNS infection. RESULTS Overall, 15,049 eligible neurosurgical records were reviewed, from which 578 surgical records of 556 patients with PA were matched to 578 records of 570 patients without PA. Patients with PA showed significantly lower probability to receive prophylactic cephalosporins (55.9% vs. 98.8%, P < 0.01), but significantly higher probability to receive clindamycin (41.86% vs. 1.03%, P < 0.01), than patients without PA. Multivariate analysis revealed that patients with PA were more likely to experience postoperative CNS infection than patients without PA (odds ratio = 2.03; 95% confidence interval, 1.15-3.56; P = 0.014). The incidence of postoperative CNS infection returned to a level comparable to that in general population when patients with suspected PA received prophylactic cephalosporins. CONCLUSIONS PA is associated with higher risk of postoperative CNS infection in patients undergoing neurosurgery. This may be attributed to the use of alternative prophylactic antibiotics other than cephalosporins, especially clindamycin.
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Affiliation(s)
- Tong Niu
- Department of Orthopedics, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, China
| | - Xinjie Bao
- Department of Neurosurgery, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, China.
| | - Junji Wei
- Department of Neurosurgery, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, China
| | - Yili Shi
- Department of Pharmacy, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, China
| | - Wenbin Ma
- Department of Neurosurgery, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, China
| | - Renzhi Wang
- Department of Neurosurgery, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, China
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Day C, Deetlefs M, O'Brien A, Smith J, Boyd M, Embling N, Patel S, Moody K, Ramabele T, Budge A, Tarwa T, Jim O, Maharaj T, Pandy S, Abrahams JM, Panieri A, Verhage S, Van der Merwe M, Geragotellis A, Amanjee W, Joseph C, Zhao Z, Moosa S, Bunting M, Pulani Y, Mukhari P, De Paiva M, Deyi G, Wonkam RP, Mancotywa N, Dunge A, Msimanga T, Singh A, Monnaruri O, Molale B, Butler TAG, Browde K, Muller C, Van der Walt J, Whitelaw R, Cronwright D, Sinha S, Binase U, Francis I, Boakye D, Dlamini S, Mendelson M, Peter J. Self-reported beta-lactam allergy in government and private hospitals in Cape Town, South Africa. S Afr Med J 2023; 113:69-74. [PMID: 36757070 DOI: 10.7196/samj.2023.v113i2.16760] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2023] [Indexed: 02/10/2023] Open
Abstract
BACKGROUND Up to a quarter of inpatients in high-income countries (HICs) self-report beta-lactam allergy (BLA), which if incorrect,increases the use of alternative antibiotics, worsening individual health outcomes and driving bacterial resistance. In HICs, up to 95% ofself-reported BLAs are incorrect. The epidemiology of BLA in low- and middle-income African countries is unknown. OBJECTIVES To describe the epidemiology and de-labelling outcomes of self-reported BLA in hospitalised South African (SA) patients. METHODS Point-prevalence surveys were conducted at seven hospitals (adult, paediatric, government and privately funded, district andtertiary level) in Cape Town, SA, between April 2019 and June 2021. Ward prescription records and in-person interviews were conductedto identify and risk-stratify BLA patients using the validated PEN-FAST tool. De-labelling was attempted at the tertiary allergy clinic atGroote Schuur Hospital. RESULTS A total of 1 486 hospital inpatients were surveyed (1 166 adults and 320 children). Only 48 patients (3.2%) self-reported a BLA,with a higher rate in private than in government-funded hospitals (6.3% v. 2.8%; p=0.014). Using the PEN-FAST tool, only 10.4% (n=5/48)of self-reported BLA patients were classified as high risk for true penicillin hypersensitivity. Antibiotics were prescribed to 70.8% (n=34/48)of self-reported BLA patients, with 64.7% (n=22/34) receiving a beta-lactam. Despite three attempts to contact patients for de-labelling atthe allergy clinic, only 3/36 underwent in vivo testing, with no positive results, and 1 patient proceeded to a negative oral challenge. CONCLUSION Unlike HICs, self-reported BLA is low among inpatients in SA. The majority of those who self-reported BLA were low risk fortype 1 hypersensitivity, but outpatient de-labelling efforts were largely unsuccessful.
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Affiliation(s)
- C Day
- Division of Allergology and Clinical Immunology, Department of Medicine, Groote Schuur Hospital and Faculty of Health Sciences, University of Cape Town, South Africa.
| | - M Deetlefs
- Division of Allergology and Clinical Immunology, Department of Medicine, Groote Schuur Hospital and Faculty of Health Sciences, University of Cape Town, South Africa.
| | - A O'Brien
- Faculty of Health Sciences, University of Cape Town, South Africa.
| | - J Smith
- Faculty of Health Sciences, University of Cape Town, South Africa.
| | - M Boyd
- Department of Medicine, Faculty of Health Sciences, University of Cape Town, South Africa.
| | - N Embling
- Faculty of Health Sciences, University of Cape Town, South Africa.
| | - S Patel
- Faculty of Health Sciences, University of Cape Town, South Africa.
| | - K Moody
- Faculty of Health Sciences, University of Cape Town, South Africa.
| | - T Ramabele
- Faculty of Health Sciences, University of Cape Town, South Africa.
| | - A Budge
- Department of Paediatrics, Faculty of Health Sciences, University of Cape Town, South Africa.
| | - T Tarwa
- Molecular Mycobacteriology Research Unit, Division of Medical Microbiology, Department of Pathology, Faculty of Health Sciences, University of Cape Town, South Africa.
| | - O Jim
- Faculty of Health Sciences, University of Cape Town, South Africa.
| | - T Maharaj
- Faculty of Health Sciences, University of Cape Town, South Africa.
| | - S Pandy
- Faculty of Health Sciences, University of Cape Town, South Africa.
| | - J-M Abrahams
- Division of Allergology and Clinical Immunology, Department of Medicine, Groote Schuur Hospital and Faculty of Health Sciences, University of Cape Town, South Africa.
| | - A Panieri
- Faculty of Health Sciences, University of Cape Town, South Africa.
| | - S Verhage
- Faculty of Health Sciences, University of Cape Town, South Africa.
| | - M Van der Merwe
- Faculty of Health Sciences, University of Cape Town, South Africa.
| | - A Geragotellis
- Faculty of Health Sciences, University of Cape Town, South Africa.
| | - W Amanjee
- Faculty of Health Sciences, University of Cape Town, South Africa.
| | - C Joseph
- Faculty of Health Sciences, University of Cape Town, South Africa.
| | - Z Zhao
- Faculty of Health Sciences, University of Cape Town, South Africa.
| | - S Moosa
- Faculty of Health Sciences, University of Cape Town, South Africa.
| | - M Bunting
- Faculty of Health Sciences, University of Cape Town, South Africa.
| | - Y Pulani
- Faculty of Health Sciences, University of Cape Town, South Africa.
| | - P Mukhari
- Faculty of Health Sciences, University of Cape Town, South Africa.
| | - M De Paiva
- Faculty of Health Sciences, University of Cape Town, South Africa.
| | - G Deyi
- Faculty of Health Sciences, University of Cape Town, South Africa.
| | - R P Wonkam
- Faculty of Health Sciences, University of Cape Town, South Africa.
| | - N Mancotywa
- Faculty of Health Sciences, University of Cape Town, South Africa.
| | - A Dunge
- Faculty of Health Sciences, University of Cape Town, South Africa.
| | - T Msimanga
- Faculty of Health Sciences, University of Cape Town, South Africa.
| | - A Singh
- Faculty of Health Sciences, University of Cape Town, South Africa.
| | - O Monnaruri
- Faculty of Health Sciences, University of Cape Town, South Africa.
| | - B Molale
- Faculty of Health Sciences, University of Cape Town, South Africa.
| | - T A G Butler
- Department of Paediatrics, Faculty of Health Sciences, University of Cape Town, South Africa.
| | - K Browde
- Division of Allergology and Clinical Immunology, Department of Paediatrics, Red Cross War Memorial Children's Hospital and Faculty of Health Sciences, University of Cape Town, South Africa.
| | - C Muller
- Allergy and Immunology Unit, University of Cape Town Lung Institute, Cape Town, South Africa.
| | - J Van der Walt
- Allergy and Immunology Unit, University of Cape Town Lung Institute, Cape Town, South Africa.
| | - R Whitelaw
- Department of Medicine, Faculty of Health Sciences, University of Cape Town, South Africa.
| | - D Cronwright
- Department of Medicine, Faculty of Health Sciences, University of Cape Town, South Africa.
| | - S Sinha
- Faculty of Health Sciences, University of Cape Town, South Africa.
| | - U Binase
- Faculty of Health Sciences, University of Cape Town, South Africa.
| | - I Francis
- Department of Medicine, Faculty of Health Sciences, University of Cape Town, South Africa.
| | - D Boakye
- Department of Medicine, Faculty of Health Sciences, University of Cape Town, South Africa.
| | - S Dlamini
- Division of Infectious Diseases and HIV Medicine, Department of Medicine, Faculty of Health Sciences, University of Cape Town, South Africa.
| | - M Mendelson
- Division of Infectious Diseases and HIV Medicine, Department of Medicine, Faculty of Health Sciences, University of Cape Town, South Africa.
| | - J Peter
- Division of Allergology and Clinical Immunology, Department of Medicine, Groote Schuur Hospital and Faculty of Health Sciences, University of Cape Town, South Africa; Allergy and Immunology Unit, University of Cape Town Lung Institute, Cape Town, South Africa.
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11
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Scaggs Huang F, Mangeot C, Sucharew H, Simon K, Courter J, Risma K, Schaffzin JK. Beta-Lactam Allergy Association with Surgical Site Infections in Pediatric Procedures: A Matched Cohort Study. J Pediatric Infect Dis Soc 2023; 12:123-127. [PMID: 36591894 DOI: 10.1093/jpids/piac138] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/14/2022] [Accepted: 12/30/2022] [Indexed: 01/03/2023]
Abstract
BACKGROUND Little is known about surgical site infection (SSI) risk among pediatric patients with reported beta-lactam allergy (BLA). METHODS We performed a retrospective cohort study at a quaternary children's hospital and compared procedures in patients ages 1-19-years-old with and without BLA that required antimicrobial prophylaxis (AMP) during 2010-2017. Procedures were matched 1:1 by patient age, complex chronic conditions, year of surgery, and National Surgical Quality Improvement Program current procedural terminology category. The primary outcome was SSI as defined by National Healthcare Safety Network. The secondary outcome was AMP protocol compliance as per American Society of Health-System Pharmacists. RESULTS Of the 11,878 procedures identified, 1021 (9%) had a reported BLA. There were 35 (1.8%) SSIs in the matched cohort of 1944 procedures with no significant difference in SSI rates in BLA procedures (1.8%) compared to no BLA (1.9%) procedures. Tier 3 AMP was chosen more frequently among BLA procedures (p<0.01). Unmatched analysis of all procedures showed that 23.7% of BLA procedures received beta-lactam-AMP (vs. 93.7% of procedures without BLA). There were no major differences in SSI on sensitivity analysis of BLA procedures that did not receive beta-lactam AMP (1.4%) compared to no BLA procedures with beta-lactam AMP (1.6%) . CONCLUSIONS Our retrospective matched analysis of 1944 pediatric procedures found no increase in SSIs in procedures with reported BLA, which differs from studies in adults. We observed that choice of beta-lactam-AMP was common, even in BLA procedures. More data are needed to delineate an association of non-beta-lactam AMP and SSI in children.
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Affiliation(s)
- Felicia Scaggs Huang
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, USA.,Division of Infectious Diseases, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Colleen Mangeot
- Division of Biostatistics and Epidemiology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Heidi Sucharew
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, USA.,Division of Biostatistics and Epidemiology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Katherine Simon
- James M Anderson Center for Health Systems Excellence, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Joshua Courter
- Division of Pharmacy, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Kimberly Risma
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, USA.,Division of Allergy and Immunology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Joshua K Schaffzin
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, USA.,Division of Infectious Diseases, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
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12
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Outcomes of Beta-Lactam Allergic and Non-Beta-Lactam Allergic Patients with Intra-Abdominal Infection: A Case-Control Study. Antibiotics (Basel) 2022; 11:antibiotics11121786. [PMID: 36551442 PMCID: PMC9774689 DOI: 10.3390/antibiotics11121786] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2022] [Revised: 12/02/2022] [Accepted: 12/08/2022] [Indexed: 12/13/2022] Open
Abstract
Background: In the case of intra-abdominal infections (IAI) in beta-lactam (BL) allergic patients, empiric antimicrobial therapy without BL is recommended; however, data regarding the outcome with alternative regimens are scarce. This study aimed to compare the outcomes of BL allergic (BLA) patients with IAI to those who were non-BLA (NBLA). Method: We conducted a case−control study in a French teaching hospital, between 1 January 2016 and 31 August 2021. BLA patients with IAI treated with fluoroquinolone or aztreonam and metronidazole were matched with controls treated with BL, on age, sex, disease severity, IAI localization, and healthcare-associated infection (HAI) status. We compared rates of therapeutic failures, adverse events, and HAI, and then assessed factors associated with therapeutic failure using a logistic regression model. Results: The therapeutic failure rate was 14% (p > 0.99) in both groups of 43 patients, and there was no significant difference in the adverse events rate (p > 0.99) and HAI rate (p = 0.154). Factors independently associated with therapeutic failure were higher BMI (OR 1.16; 95%CI [1.00−1.36]; p = 0.041), longer hospital length of stay (OR 1,20; 95%CI [1.08−1.41]; p = 0.006), and inadequate empiric antimicrobial therapy (OR 11.71; 95%CI [1.43−132.46]; p = 0.025). Conclusion: The outcomes of BLA patients with IAI treated without BL were the same as those for NBLA patients treated with BL.
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13
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Khan DA, Banerji A, Blumenthal KG, Phillips EJ, Solensky R, White AA, Bernstein JA, Chu DK, Ellis AK, Golden DBK, Greenhawt MJ, Horner CC, Ledford D, Lieberman JA, Oppenheimer J, Rank MA, Shaker MS, Stukus DR, Wallace D, Wang J, Khan DA, Golden DBK, Shaker M, Stukus DR, Khan DA, Banerji A, Blumenthal KG, Phillips EJ, Solensky R, White AA, Bernstein JA, Chu DK, Ellis AK, Golden DBK, Greenhawt MJ, Horner CC, Ledford D, Lieberman JA, Oppenheimer J, Rank MA, Shaker MS, Stukus DR, Wallace D, Wang J. Drug allergy: A 2022 practice parameter update. J Allergy Clin Immunol 2022; 150:1333-1393. [PMID: 36122788 DOI: 10.1016/j.jaci.2022.08.028] [Citation(s) in RCA: 173] [Impact Index Per Article: 86.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2022] [Revised: 08/18/2022] [Accepted: 08/30/2022] [Indexed: 12/14/2022]
Affiliation(s)
- David A Khan
- Department of Internal Medicine, Division of Allergy and Immunology, University of Texas Southwestern Medical Center, Dallas, Tex
| | - Aleena Banerji
- Department of Internal Medicine, Division of Rheumatology, Allergy and Immunology, Massachusetts General Hospital, Boston, Mass
| | - Kimberly G Blumenthal
- Department of Internal Medicine, Division of Rheumatology, Allergy and Immunology, Massachusetts General Hospital, Boston, Mass
| | - Elizabeth J Phillips
- Institute for Immunology and Infectious Diseases, Murdoch University, Murdoch, Western Australia; Department of Medicine, Vanderbilt University Medical Center, Nashville, Tenn
| | - Roland Solensky
- Corvallis Clinic, Oregon State University/Oregon Health Science University College of Pharmacy, Corvallis, Ore
| | - Andrew A White
- Department of Allergy, Asthma and Immunology, Scripps Clinic, San Diego, Calif
| | - Jonathan A Bernstein
- Department of Internal Medicine, Division of Immunology, Allergy Section, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Derek K Chu
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada; Department of Medicine, McMaster University, Hamilton, Ontario, Canada; The Research Institute of St Joe's Hamilton, Hamilton, Ontario, Canada
| | - Anne K Ellis
- Division of Allergy and Immunology, Department of Medicine, Queen's University, Kingston, Ontario, Canada
| | - David B K Golden
- Division of Allergy and Clinical Immunology, Johns Hopkins University School of Medicine, Baltimore, Md
| | - Matthew J Greenhawt
- Food Challenge and Research Unit Section of Allergy and Immunology, Children's Hospital Colorado University of Colorado School of Medicine, Aurora, Colo
| | - Caroline C Horner
- Department of Pediatrics, Division of Allergy Pulmonary Medicine, Washington University School of Medicine, St Louis, Mo
| | - Dennis Ledford
- Division of Allergy and Immunology, Department of Medicine, University of South Florida Morsani College of Medicine, Tampa, Fla; James A. Haley Veterans Affairs Hospital, Tampa, Fla
| | - Jay A Lieberman
- Division of Allergy and Immunology, The University of Tennessee Health Science Center, Memphis, Tenn
| | - John Oppenheimer
- Division of Allergy, Rutgers New Jersey Medical School, Rutgers, NJ
| | - Matthew A Rank
- Division of Allergy, Asthma, and Clinical Immunology, Mayo Clinic in Arizona, Scottsdale, Ariz
| | - Marcus S Shaker
- Department of Pediatrics, Dartmouth-Hitchcock Medical Center, Lebanon, NH
| | - David R Stukus
- Division of Allergy and Immunology, Nationwide Children's Hospital, Columbus, Ohio; The Ohio State University College of Medicine, Columbus, Ohio
| | - Dana Wallace
- Nova Southeastern Allopathic Medical School, Fort Lauderdale, Fla
| | - Julie Wang
- Division of Allergy and Immunology, Department of Pediatrics, The Elliot and Roslyn Jaffe Food Allergy Institute, Icahn School of Medicine at Mount Sinai, New York, NY
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14
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Chung WTG, Shafi H, Seah J, Purnima P, Patun T, Kam KQ, Seah VXF, Ong RYL, Lin L, Choo RSM, Lingegowda P, Lim CLL, Chung JS, Chua NGSY, Lee TH, Yap MY, Ng TM, Somani J. National surgical antibiotic prophylaxis guideline in Singapore. ANNALS OF THE ACADEMY OF MEDICINE, SINGAPORE 2022. [DOI: 10.47102/annals-acadmedsg.2022273] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Introduction: Institutional surgical antibiotic prophylaxis (SAP) guidelines are in place at all public hospitals in Singapore, but variations exist and adherence to guidelines is not tracked consistently. A national point prevalence survey carried out in 2020 showed that about 60% of surgical prophylactic antibiotics were administered for more than 24 hours. This guideline aims to align best practices nationally and provides a framework for audit and surveillance.
Method: This guideline was developed by the National Antimicrobial Stewardship Expert Panel’s National Surgical Antibiotic Prophylaxis Guideline Development Workgroup Panel, which comprises infectious diseases physicians, pharmacists, surgeons and anaesthesiologists. The Workgroup adopted the ADAPTE methodology framework with modifications for the development of the guideline. The recommended duration of antibiotic prophylaxis was graded according to the strength of consolidated evidence based on the scoring system of the Singapore Ministry of Health Clinical Practice Guidelines.
Results: This National SAP Guideline provides evidence-based recommendations for the rational use of antibiotic prophylaxis. These include recommended agents, dose, timing and duration for patients undergoing common surgeries based on surgical disciplines. The Workgroup also provides antibiotic recommendations for special patient population groups (such as patients with β-lactam allergy and patients colonised with methicillin-resistant Staphylococcus aureus), as well as for monitoring and surveillance of SAP.
Conclusion: This evidence-based National SAP Guideline for hospitals in Singapore aims to align practices and optimise the use of antibiotics for surgical prophylaxis for the prevention of surgical site infections while reducing adverse events from prolonged durations of SAP.
Keywords: Antibiotic prophylaxis duration, antimicrobial resistance, antimicrobial stewardship, hospital-acquired infection, surgical site infections
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Affiliation(s)
| | | | | | | | | | | | | | | | - Li Lin
- Ng Teng Fong General Hospital, Singapore
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15
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Mowrer C, Lyden E, Matthews S, Abbas A, Bergman S, Alexander BT, Van Schooneveld TC, Stohs EJ. Beta-lactam allergies, surgical site infections, and prophylaxis in solid organ transplant recipients at a single center: A retrospective cohort study. Transpl Infect Dis 2022; 24:e13907. [PMID: 36254522 PMCID: PMC9787036 DOI: 10.1111/tid.13907] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2022] [Revised: 06/07/2022] [Accepted: 06/13/2022] [Indexed: 11/06/2022]
Abstract
BACKGROUND Beta-lactam allergies (BLAs) are common in hospitalized patients, including transplant recipients. BLA is associated with decreased use of preferred surgical site infection (SSI) prophylaxis and increased SSIs, but this has not been studied in the transplant population. METHODS We reviewed adult heart, kidney, and liver transplant recipients between January 1, 2016 and December 31, 2019 to characterize reported BLA and collect SSI prophylaxis regimens at time of transplant. We compared the use of preferred SSI prophylaxis and SSI incidence based on reported BLA status. Post hoc we collected antibiotic days of therapy (DOT) (excluding pneumocystis prophylaxis) in the 30-day period posttransplant for patients without SSI. We utilized descriptive statistics for comparisons. RESULTS Of 691 patients included (116 heart, 400 kidney, and 175 liver transplant recipients), 118 (17%) reported BLA. Rash and hives were the two most reported BLA reactions (36% and 24%), categorized as potential T-cell mediated and IgE mediated, respectively. Preferred SSI prophylaxis was prescribed in 13 (11%) patients with BLA and 573 (92%) without BLA (p < .001). No difference could be detected in SSI incidence between BLA and non-BLA patients (4.2 vs. 4.3%, p = 1.0). Of 659 without SSI, 169 (25.6%) received antibiotics within 30 days of transplant; mean antibiotic DOT for BLA and non-BLA patients were 3.5 ± 8.0 versus 2.3 ± 5.8, p = .12. CONCLUSION BLA transplant recipients received nonpreferred SSI prophylaxis more frequently than non-BLA recipients, but there was no difference in 30-day SSIs between the groups. One-fourth of solid organ transplant recipients received systemic antibiotics within 30 days of transplant.
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Affiliation(s)
- Clayton Mowrer
- Division of Infectious DiseasesDepartment of MedicineUniversity of Nebraska Medical CenterOmahaNebraskaUSA
| | - Elizabeth Lyden
- Department of BiostatisticsCollege of Public HealthUniversity of Nebraska Medical CenterOmahaNebraskaUSA
| | - Stephen Matthews
- Infection Control and EpidemiologyNebraska MedicineOmahaNebraskaUSA
| | - Anum Abbas
- Division of Infectious DiseasesDepartment of MedicineUniversity of Nebraska Medical CenterOmahaNebraskaUSA
| | - Scott Bergman
- Department of Pharmaceutical and Nutritional CareNebraska MedicineOmahaNebraskaUSA
| | - Bryan T. Alexander
- Department of Pharmaceutical and Nutritional CareNebraska MedicineOmahaNebraskaUSA
| | - Trevor C. Van Schooneveld
- Division of Infectious DiseasesDepartment of MedicineUniversity of Nebraska Medical CenterOmahaNebraskaUSA
| | - Erica J. Stohs
- Division of Infectious DiseasesDepartment of MedicineUniversity of Nebraska Medical CenterOmahaNebraskaUSA
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16
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A work in progress: antimicrobial stewardship in solid organ transplant patient populations. Curr Opin Infect Dis 2022; 35:363-369. [PMID: 35849527 DOI: 10.1097/qco.0000000000000848] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW To review recent medical literature addressing antimicrobial stewardship in solid organ transplant (SOT) recipients. RECENT FINDINGS Few studies with a strict focus on SOT patients have been published to date. Team-based antimicrobial stewardship interventions in SOT populations do have beneficial impacts on antimicrobial stewardship-relevant outcomes. Several studies have compared SOT-specific antibiograms to widely accepted hospital antibiograms; these studies all have found important differences in resistance rates among bacterial pathogens. Novel biomarkers like virome monitoring for assessing the net state of immunosuppression hold promise for individualized antimicrobial stewardship interventions. SUMMARY SOT patients are an understudied population with respect to antimicrobial stewardship interventions. Current antimicrobial stewardship interventions for SOT patients are largely extrapolated from studies in general patient populations and may not accurately reflect SOT-specific infection risks or outcomes. Antimicrobial stewardship interventions do impact SOT-relevant care goals but require significantly more research to achieve the depth and reach of antimicrobial stewardship interventions developed for general populations.
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17
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Tabata S, Kamide T, Suzuki K, Kurita H. Predictive factors for bone flap infection after cranioplasty. J Clin Neurosci 2022; 98:219-223. [DOI: 10.1016/j.jocn.2022.02.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2021] [Revised: 02/11/2022] [Accepted: 02/14/2022] [Indexed: 10/19/2022]
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18
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Clindamycin use in head and neck surgery elevates the rate of infections in tracheostomies. Eur Arch Otorhinolaryngol 2022; 279:3581-3586. [PMID: 35333962 PMCID: PMC9130157 DOI: 10.1007/s00405-022-07349-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2021] [Accepted: 03/08/2022] [Indexed: 11/18/2022]
Abstract
Background Surgical site infection (SSI) in open surgical tracheostomy (ST) occurs in up to 33% of the cases. SSI can be reduced by a postoperative antibiotic prophylaxis (POAP). The effect of Clindamycin on SSIs in head and neck surgery (HNS) is discussed controversially in the literature. Methods An 8 year single-center retrospective comparative analysis of 441 STs (Visor-ST and Bjoerk-flap technique) performed within major HNS was evaluated due to the event of a SSI within 7 days and analyzed descriptively. Logistic regression model evaluated the impact of POAP with Clindamycin on SSIs. Results The use of Clindamycin showed twice the rate of ST-SSI as all patients that did not receive Clindamycin, treated with other perioperative antibiotics. (Fisher’s p = 0.008) The logistic regression model could not prove a statistically significant impact. (OR = 2.91, p = 0.04). Conclusion We recommend that Clindamycin should be reconsidered as a POAP regimen in ST. Further studies should evaluate alternatives for Penicillin-allergic patients. Level of evidence III Comparative retrospective monocentric study.
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19
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Johnston C, Godecker A, Shirley D, Antony KM. Documented β-Lactam Allergy and Risk for Cesarean Surgical Site Infection. Infect Dis Obstet Gynecol 2022; 2022:5313948. [PMID: 35281850 PMCID: PMC8906943 DOI: 10.1155/2022/5313948] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2021] [Revised: 01/27/2022] [Accepted: 02/15/2022] [Indexed: 11/17/2022] Open
Abstract
Objective To examine the relationship between documented β-lactam allergy and cesarean delivery (CD) surgical site infection (SSI). Study Design. We conducted a retrospective cohort analysis of women who underwent CD at Ben Taub Hospital and Texas Children's Pavilion for Women (Houston, TX) from August 1, 2011, to December 31, 2019. The primary exposure was a documented β-lactam allergy, and the second exposure of interest was the type of perioperative antibiotic received. The primary outcome was the prevalence of SSI. Maternal characteristics were stratified by the presence or absence of a documented β-lactam allergy, and significance was evaluated using Pearson's chi-squared test for categorical variables and t-test for continuous variables. A logistic regression model estimated odds of SSI after adjusting for possible confounders. Results Of the 12,954 women included, 929 (7.2%) had a documented β-lactam allergy while 12,025 (92.8%) did not. Among the 929 women with a β-lactam allergy, 495 (53.3%) received non-β-lactam perioperative prophylaxis. SSI occurred in 38 (4.1%) of women who had a β-lactam allergy versus 238 (2.0%) who did not (p ≤ 0.001). β-Lactam allergy was associated with higher odds of SSI compared to no allergy (adjusted odds ratio (aOR) = 1.97; 95%confidence interval (CI) = 1.24-3.14; p = 0.004) after controlling for age, race, ethnicity, insurance status, delivery body mass index (BMI), tobacco use, intra-amniotic infection in labor, duration of membrane rupture, preterm delivery, delivery indication, diabetes, hypertension, group B Streptococcus colonization, and type of perioperative antibiotic received. Conclusion The presence of a β-lactam allergy is associated with increased odds of developing a CD SSI after controlling for possible confounders, including the type of perioperative antibiotic received.
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Affiliation(s)
- Courtney Johnston
- University of Wisconsin School of Medicine and Public Health, 750 Highland Ave, Madison, WI 53726, USA
| | - Amy Godecker
- Department of Obstetrics and Gynecology, University of Wisconsin School of Medicine and Public Health, 1010 Mound Street Madison, WI 53715, USA
| | - Daniel Shirley
- Division of Infectious Diseases, Department of Medicine, University of Wisconsin School of Medicine and Public Health, 1685 Highland Avenue, 5158 Medical Foundation Centennial Building, Madison WI 53705-2281, USA
| | - Kathleen M. Antony
- Department of Obstetrics and Gynecology, University of Wisconsin School of Medicine and Public Health, 1010 Mound Street Madison, WI 53715, USA
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20
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Minaldi E, Phillips EJ, Norton A. Immediate and Delayed Hypersensitivity Reactions to Beta-Lactam Antibiotics. Clin Rev Allergy Immunol 2021; 62:449-462. [PMID: 34767158 DOI: 10.1007/s12016-021-08903-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/10/2021] [Indexed: 12/16/2022]
Abstract
Beta-lactam antibiotics are the most commonly reported drug allergy in adults and children. More than 95% of those with reported allergy labels to beta lactams are not confirmed when subjected to allergy testing. Beta lactam antibiotics are associated with a wide spectrum of immediate and delayed drug hypersensitivity reactions. The latency period to symptoms and clinical presentation aids in the causality assessment. Risk stratification based on diagnosis and timing then allows for appropriate management and evaluation. Skin prick testing, intradermal testing and oral challenge are well established for evaluation of immediate reactions. Delayed intradermal testing, patch testing and oral challenge can also be considered for evaluation of mild to moderate delayed reactions. Cross-reactivity between beta-lactams appears to be driven most commonly by a shared R1 side-chain. Standardized algorithms, protocols and pathways are needed for widespread implementation of a pragmatic and effective approach to patients reporting beta lactam allergy.
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Affiliation(s)
- Ellen Minaldi
- Department of Pediatrics, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Elizabeth J Phillips
- Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA.
| | - Allison Norton
- Division of Allergy, Immunology, and Pulmonary Medicine, Department of Pediatrics, Vanderbilt University Medical Center, Nashville, TN, USA
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Roistacher DM, Heller JA, Ferraro NF, August M. Is Penicillin Allergy a Risk Factor for Surgical Site Infection After Oral and Maxillofacial Surgery? J Oral Maxillofac Surg 2021; 80:93-100. [PMID: 34547269 DOI: 10.1016/j.joms.2021.08.147] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2021] [Revised: 08/09/2021] [Accepted: 08/10/2021] [Indexed: 12/11/2022]
Abstract
PURPOSE The selection of perioperative antibiotics for prevention of surgical site infection (SSI) is often limited by the presence of a reported penicillin allergy. The purpose of this study was to determine if oral and maxillofacial surgery patients who report allergy to penicillin are at an increased risk of developing SSI. METHODS A retrospective cohort study was performed of patients who underwent oral and maxillofacial surgical procedures in the operating room setting at a single institution between 2011 and 2018. The following categories of procedures were investigated: dentoalveolar, orthognathic, orthognathic with third molar extraction, pathology and reconstruction, and temporomandibular joint. The primary predictor and outcome variables were reported penicillin allergy and surgical site infection, respectively. Bivariate and multiple logistic regression analysis were performed. P < .05 was considered to be significant. RESULTS The cohort was composed of 2,058 patients of which 318 (15.5%) reported allergy to penicillin. Beta-lactam antibiotics were administered less frequently to penicillin allergic patients perioperatively compared with those without penicillin allergy (7.9 vs 97.1%, P < .001), while clindamycin was more commonly administered (76.4 vs 2.5%, P < .001). Clindamycin was associated with a higher SSI rate compared with beta-lactam antibiotics (5.6 vs 1.4%, P < .001). Penicillin allergy was significantly associated with SSI at an adjusted odds ratio of 2.61 (95% CI 1.51 to 4.49, P = .001). After holding perioperative antibiotic usage equal between the 2 groups, penicillin allergy per se was no longer associated with SSI (P = .901), suggesting that the outcome was mediated by antibiotic selection. CONCLUSIONS Penicillin allergy was associated with development of SSI due to receipt of non-beta-lactam antibiotics as perioperative prophylaxis. Formal allergy evaluation should be considered for patients with putative penicillin allergy.
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Affiliation(s)
- Daniel M Roistacher
- Resident, Oral and Maxillofacial Surgery, Mount Sinai Health System, New York, NY.
| | | | - Nalton F Ferraro
- Instructor, Oral and Maxillofacial Surgery, Harvard School of Dental Medicine, Boston, MA
| | - Meredith August
- Attending Surgeon, Department of Oral and Maxillofacial Surgery, Massachusetts General Hospital, Boston, MA
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Fosnot S, Currier K, Pendell J, Jeffres MN. Comparison of immediate hypersensitivity reactions to preoperative antibiotics in patients labeled as penicillin allergic. Surgery 2021; 170:777-782. [PMID: 33838879 DOI: 10.1016/j.surg.2021.02.063] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2020] [Revised: 02/23/2021] [Accepted: 02/26/2021] [Indexed: 11/18/2022]
Abstract
BACKGROUND Cefazolin is routinely recommended as the first-line agent for surgical antibiotic prophylaxis because it prevents more surgical site infections than second-line antibiotics. Clinicians often avoid administering cefazolin to patients who are labeled as penicillin allergic due to concerns of cross-reactivity. The aim of this study was to compare the incidence of hypersensitivity reactions between cefazolin and the second-line antibiotics vancomycin and clindamycin. METHODS This retrospective study included patients who were labeled as penicillin allergic and received either cefazolin, clindamycin, or vancomycin as preoperative antibiotics. The primary outcome was intraoperative hypersensitivity reactions. RESULTS A total of 734 surgical procedures in 690 patients were included. Fifteen immediate hypersensitivity reactions were identified. Probable hypersensitivity reactions occurred in 3 (0.9%) patients in the cefazolin group, 4 (1.4%) in the clindamycin group, and 1 (1.1%) in the vancomycin group. Seven of 8 patients reported allergies to additional medications beyond penicillin. There were seven cases of possible hypersensitivity reactions, 3 (0.9%) in the cefazolin group, 1 (1.1%) in the vancomycin group, and 3 (1.0%) in the clindamycin group. CONCLUSION Our data suggest that perioperative hypersensitivity reactions are uncommon in patients labeled as penicillin allergic. The frequency of immediate hypersensitivity reactions was not different between patients receiving cefazolin, clindamycin, or vancomycin. Avoiding cefazolin in patients labeled as penicillin allergic may not be warranted.
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Affiliation(s)
- Spencer Fosnot
- University of Colorado Anschutz Medical Campus, Skaggs School of Pharmacy and Pharmaceutical Sciences, Aurora, CO
| | - Katelyn Currier
- University of Colorado Anschutz Medical Campus, Skaggs School of Pharmacy and Pharmaceutical Sciences, Aurora, CO
| | - Jay Pendell
- University of Colorado Anschutz Medical Campus, Skaggs School of Pharmacy and Pharmaceutical Sciences, Aurora, CO
| | - Meghan N Jeffres
- University of Colorado Anschutz Medical Campus, Skaggs School of Pharmacy and Pharmaceutical Sciences, Aurora, CO.
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Investigating the impact of a β-lactam allergy label on preoperative antibiotic prophylaxis administration. Infect Control Hosp Epidemiol 2020; 42:710-714. [PMID: 33198838 DOI: 10.1017/ice.2020.1271] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
OBJECTIVE Surgical site infection (SSI) is a common postprocedure complication that may be prevented by adhering to established recommendations, including administration of preoperative antibiotic prophylaxis. Patients with a β-lactam allergy (BLA) label have an increased risk of SSI. We sought to evaluate the appropriateness of preoperative antibiotic prophylaxis in patients labeled with a BLA compared those without a BLA. METHODS This was a single-center, retrospective, matched cohort study of adult patients who underwent a clean or clean-contaminated knee replacement, abdominal hysterectomy, colorectal surgery, or coronary artery bypass graft (CABG). Patients with a BLA label were matched to patients without a BLA label based on procedure, age, and body mass index (BMI). The primary end point was the rate of appropriate preoperative antibiotic prophylaxis, including antibiotic selection and timing prior to incision. RESULTS In total, 260 patients were included. Knee replacement (38%) was the most common procedure, followed by abdominal hysterectomy (25%), colorectal surgery (18%), and CABG (18%). Appropriate preoperative antibiotic prophylaxis was higher among patients without a BLA (76% vs 37%; P < .001). Among patients with a mild-to-moderate reaction or intolerance, 29 (53%) received antibiotics that would have been appropriate only if the patient had had a severe BLA. Patients with a BLA were more likely to have had an antibiotic omitted from the prophylactic regimen (44% vs 4%; P < .001). CONCLUSION Patients with a BLA were more likely to receive inappropriate preoperative antibiotic prophylaxis, attributed to misinterpretation of BLA labels and antibiotic omissions. Optimizing antibiotic prophylaxis among patients with BLAs remains an area of opportunity to prevent SSIs.
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Plager JH, Mancini CM, Fu X, Melnitchouk S, Shenoy ES, Banerji A, Collier L, Chaudhary N, Yerneni S, Zhang Y, Blumenthal KG. Preoperative penicillin allergy testing in patients undergoing cardiac surgery. Ann Allergy Asthma Immunol 2020; 124:583-588. [PMID: 32217188 DOI: 10.1016/j.anai.2020.03.013] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2020] [Revised: 03/09/2020] [Accepted: 03/15/2020] [Indexed: 12/18/2022]
Abstract
BACKGROUND Cefazolin is a first-line prophylactic antibiotic used to prevent surgical site infections (SSIs) in cardiac surgery. Patients with a history of penicillin allergy often receive less effective second-line antibiotics, which is associated with an increased SSI risk. OBJECTIVE To describe the impact of preoperative penicillin allergy evaluation on perioperative cefazolin use in patients undergoing cardiac surgery. METHODS We performed a retrospective cohort study of patients with a documented penicillin allergy who underwent cardiac surgery at the Massachusetts General Hospital from September 2015 to December 2018. We describe penicillin allergy evaluation assessment and outcomes. We evaluated the association between preoperative penicillin allergy evaluation and first-line perioperative antibiotic use using a multivariable logistic regression model. RESULTS Of 3802 cardiac surgical patients, 510 (13%) had a documented penicillin allergy; 165 (33%) were referred to allergy and immunology practitioners. Of 160 patients (31%) who underwent penicillin allergy evaluation (ie, penicillin skin testing and, if results were negative, an amoxicillin challenge), 154 (97%) were found not to have a penicillin allergy. Patients who underwent preoperative penicillin allergy evaluation were more likely to receive the first-line perioperative antibiotic (92% vs 38%, P < .001). After adjusting for potential confounders, patients who underwent preoperative penicillin allergy evaluation had higher odds of first-line perioperative antibiotic use (adjusted odds ratio, 26.6; 95% CI, 12.8-55.2). CONCLUSION Integrating penicillin allergy evaluation into routine preoperative care ensured that almost all evaluated patients undergoing cardiac surgery received first-line antibiotic prophylaxis, a critical component of SSI risk reduction. Further efforts are needed to increase access to preoperative allergy evaluation.
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Affiliation(s)
- Jessica H Plager
- Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts
| | - Christian M Mancini
- Division of Rheumatology, Allergy, and Immunology, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts; Medical Practice Evaluation Center, Massachusetts General Hospital, Boston, Massachusetts; The Mongan Institute, Massachusetts General Hospital, Boston, Massachusetts
| | - Xiaoqing Fu
- Division of Rheumatology, Allergy, and Immunology, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts; Medical Practice Evaluation Center, Massachusetts General Hospital, Boston, Massachusetts; The Mongan Institute, Massachusetts General Hospital, Boston, Massachusetts
| | - Serguei Melnitchouk
- Department of Surgery, Massachusetts General Hospital, Boston, Massachusetts; Harvard Medical School, Boston, Massachusetts
| | - Erica S Shenoy
- Harvard Medical School, Boston, Massachusetts; Division of Infectious Diseases, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts; Infection Control Unit, Massachusetts General Hospital, Boston, Massachusetts
| | - Aleena Banerji
- Division of Rheumatology, Allergy, and Immunology, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts; Harvard Medical School, Boston, Massachusetts
| | - Laura Collier
- Department of Surgery, Massachusetts General Hospital, Boston, Massachusetts
| | - Nivedita Chaudhary
- Division of Rheumatology, Allergy, and Immunology, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts
| | - Sharmitha Yerneni
- Division of General Internal Medicine and Primary Care, Brigham and Women's Hospital, Boston, Massachusetts
| | - Yuqing Zhang
- Division of Rheumatology, Allergy, and Immunology, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts; The Mongan Institute, Massachusetts General Hospital, Boston, Massachusetts; Harvard Medical School, Boston, Massachusetts
| | - Kimberly G Blumenthal
- Division of Rheumatology, Allergy, and Immunology, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts; Medical Practice Evaluation Center, Massachusetts General Hospital, Boston, Massachusetts; The Mongan Institute, Massachusetts General Hospital, Boston, Massachusetts; Harvard Medical School, Boston, Massachusetts.
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