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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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2
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Morales Martínez Á. [Penicillin allergy: A label that is not forever]. Semergen 2024; 50:102280. [PMID: 38936101 DOI: 10.1016/j.semerg.2024.102280] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2024] [Revised: 02/28/2024] [Accepted: 03/15/2024] [Indexed: 06/29/2024]
Abstract
Self-reported penicillin allergy is highly prevalent. Different studies estimate that 10% of the population is labeled as such. This label, confirmed or suspected, forces us to take precautions and replace the antibiotic treatment of choice (frequently beta-lactams) with other 2nd or 3rd choice alternatives with worse overall results: side effects, resistance, costs, etc. The penicillin allergy label, once placed, remains in the medical record. It is only confirmed in less than 5% of patients, either because it has been placed inappropriately or because over time the sensitivity decreases and may disappear. Penicillin Allergy Decision Rule -PEN-FAST- is a validated and simple clinical prediction rule that estimates the risk of presenting an allergic reaction. Its use, together with algorithms that involve primary care in the study and delabeling of low-risk patients, can change our clinical practice.
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Affiliation(s)
- Á Morales Martínez
- Servicio de Salud del Principado de Asturias, Medicina Familiar y Comunitaria, Centro de salud de Natahoyo, Área Sanitaria V, Gijón, Asturias, España; Medicina Familiar y Comunitaria, Universidad de Oviedo, Oviedo, España.
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3
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Porto JR, Lavu MS, Hecht CJ, McNassor R, Burkhart RJ, Kamath AF. Is Penicillin Allergy a Clinical Problem? A Systematic Review of Total Joint Arthroplasty Procedures With Implications for Patient Safety and Antibiotic Stewardship. J Arthroplasty 2024; 39:1616-1623. [PMID: 38040064 DOI: 10.1016/j.arth.2023.11.034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/13/2023] [Revised: 11/24/2023] [Accepted: 11/27/2023] [Indexed: 12/03/2023] Open
Abstract
BACKGROUND Patients undergoing total joint arthroplasty (TJA) who report penicillin allergy (PA) are frequently administered second-line antibiotics, although recent evidence suggests that this may be unnecessary and could increase infection risk. Many institutions have aimed to improve antibiotic deployment via allergy testing and screening; however, there is little standardization to this process. This review aimed to evaluate (1) antibiotic selection in patients who report PA and assess the impact of screening and testing interventions, (2) rates of allergic reactions in patients who report PA, and (3) the association between reported PA and screening or testing programs and odds of surgical site infection or periprosthetic joint infection. METHODS PubMed, EBSCOhost, and Google Scholar electronic databases were searched on February 4, 2023 to identify all studies published since January 1, 2000 that evaluated the impact of PA on patients undergoing TJA (PROSPERO study protocol registration: CRD42023394031). Articles were included if full-text manuscripts in English were available, and the study analyzed the impact of PA and related interventions on TJA patients. There were 11 studies evaluating 1,276,663 patients included. Interventions were compared via presentation of key findings regarding rates of clinically relevant or high-risk PA reported upon screenings or testings, cephalosporin utilizations, allergic reactions, and postoperative infections (surgical site infection and periprosthetic joint infection). RESULTS All 6 studies found that PA screening and testing markedly increase the use of first-line antibiotics. Testing showed low rates of true allergy (0.7 to 3%) and allergic reaction frequency for patients who have reported PA receiving cephalosporins was between 0% and 2%. Although there were mixed findings across studies, there was a trend toward second-line antibiotic prophylaxis being associated with a slightly higher rate of infection in PA patients. CONCLUSIONS Using PA screening and testing can promote antibiotic stewardship by safely increasing the use of first-line antibiotics in patients who have a reported PA. LEVEL OF EVIDENCE Level III, Therapeutic Study.
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Affiliation(s)
- Joshua R Porto
- Department of Orthopaedic Surgery, Cleveland Clinic Foundation, Cleveland, Ohio
| | - Monish S Lavu
- Department of Orthopaedic Surgery, Cleveland Clinic Foundation, Cleveland, Ohio
| | - Christian J Hecht
- Department of Orthopaedic Surgery, Cleveland Clinic Foundation, Cleveland, Ohio
| | - Ryan McNassor
- Department of Orthopaedic Surgery, Beaumont Health, Royal Oak, Michigan
| | - Robert J Burkhart
- Department of Orthopaedic Surgery, University Hospitals, Cleveland, Ohio
| | - Atul F Kamath
- Department of Orthopaedic Surgery, Cleveland Clinic Foundation, Cleveland, Ohio
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4
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Bukowski BR, Torres-Ramirez RJ, Devine D, Chiu YF, Carli AV, Maalouf DB, Goytizolo EA, Miller AO, Rodriguez JA. Perioperative Cefazolin for Total Joint Arthroplasty Patients Who Have a Penicillin Allergy: Is It Safe? J Arthroplasty 2024:S0883-5403(24)00381-4. [PMID: 38677347 DOI: 10.1016/j.arth.2024.04.058] [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: 12/13/2023] [Revised: 04/11/2024] [Accepted: 04/16/2024] [Indexed: 04/29/2024] Open
Abstract
BACKGROUND Cefazolin is the standard of care for perioperative antibiotic prophylaxis in total joint arthroplasty (TJA) in the United States. The potential allergic cross-reactivity between cefazolin and penicillin causes uncertainty regarding optimal antibiotic choice in patients who have a reported penicillin allergy (rPCNA). The purpose of this study was to determine the safety of perioperative cefazolin in PCNA patients undergoing primary TJA. METHODS We identified all patients (n = 49,842) undergoing primary total hip arthroplasty (n = 25,659) or total knee arthroplasty (n = 24,183) from 2016 to 2022 who received perioperative intravenous antibiotic prophylaxis. Patients who had an rPCNA (n = 5,508) who received cefazolin (n = 4,938, 89.7%) were compared to rPCNA patients who did not (n = 570, 10.3%), and to patients who did not have an rPCNA (n = 43,359). The primary outcome was the rate of allergic reactions within 72 hours postoperatively. Secondary outcomes included the rates of superficial infections, deep infections, and Clostridioides difficile infections within 90 days. RESULTS The rate of allergic reactions was 0.1% (n = 5) in rPCNA patients who received cefazolin, compared to 0.2% (n = 1) in rPCNA patients who did not (P = .48) and 0.02% (n = 11) in patients who have no rPCNA (P = .02). Allergic reactions were mild in all 5 rPCNA patients who received cefazolin and were characterized by cutaneous symptoms (n = 4) or dyspnea in the absence of respiratory distress (n = 1) that resolved promptly with antibiotic discontinuation and administration of antihistamines and/or corticosteroids. We observed no differences in the rates of superficial infections (0.1 versus 0.2%, P = .58), deep infections (0.3 versus 0.4%, P = .68), or C difficile infections (0.04% versus 0%, P = .99) within 90 days in rPCNA patients who received cefazolin versus alternative perioperative antibiotics. CONCLUSIONS In this series of more than 5,500 patients who had an rPCNA undergoing primary TJA, perioperative prophylaxis with cefazolin resulted in a 0.1% incidence of allergic reactions that were clinically indolent. Cefazolin can be safely administered to most patients, independent of rPCNA severity. LEVEL OF EVIDENCE III.
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Affiliation(s)
- Brandon R Bukowski
- Department of Orthopedic Surgery, Hospital for Special Surgery, New York, New York
| | | | - Daniel Devine
- Department of Orthopedic Surgery, Hospital for Special Surgery, New York, New York
| | - Yu-Fen Chiu
- Biostatistics Core, Hospital for Special Surgery, New York, New York
| | - Alberto V Carli
- Department of Orthopedic Surgery, Hospital for Special Surgery, New York, New York
| | - Daniel B Maalouf
- Department of Anesthesiology, Hospital for Special Surgery, New York, New York
| | - Enrique A Goytizolo
- Department of Anesthesiology, Hospital for Special Surgery, New York, New York
| | - Andy O Miller
- Division of Infectious Disease, Department of Internal Medicine, Hospital for Special Surgery, New York, New York
| | - Jose A Rodriguez
- Department of Orthopedic Surgery, Hospital for Special Surgery, New York, New York
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Schroeder MJ, Kraft CT, Janis JE, Kraft MT. Diagnosis and Treatment of Perioperative Allergic Complications: A Practical Review. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2024; 12:e5734. [PMID: 38623441 PMCID: PMC11018239 DOI: 10.1097/gox.0000000000005734] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2023] [Accepted: 02/23/2024] [Indexed: 04/17/2024]
Abstract
Background Reported drug allergies are commonly encountered by surgeons and can lead to uncertainty in selecting an appropriate agent due to concerns of associated risks with related and cross-reactive drugs. This uncertainty can ultimately lead to increased infection rates. Methods A literature review was conducted in PubMed using a combination of the terms "allergy," "allergic reaction," "anaphylaxis," and "surgery," "surgical," or "operating room" for articles published within the last 10 years. Publications identified with these search terms were then filtered for review articles, sorted by "best match," and a maximum of 100 articles were manually reviewed for each combination of search terms. Results Search results yielded 46,484 articles, 676 of which were ultimately included for manual review, based on selection criteria. Specifically, articles selected for inclusion focused on surgical allergic reactions that were either related to mechanism of action, causative agent for the allergic reaction, timing of allergic reaction, or recommendations for appropriate management. Conclusions Allergic reactions can be a common occurrence in the operative room. Knowledge of likely causative agents, timing of a reaction to various agents, and appropriate management in the immediate and delayed setting can improve outcomes and safety for plastic surgery patients.
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Affiliation(s)
- Michael J. Schroeder
- From the Department of Plastic and Reconstructive Surgery, Ohio State University, Columbus, Ohio
| | | | - Jeffrey E. Janis
- From the Department of Plastic and Reconstructive Surgery, Ohio State University, Columbus, Ohio
| | - Monica T. Kraft
- Department of Otolaryngology, Division of Allergy and Immunology, Ohio State University, Columbus, Ohio
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Sexton ME, Kuruvilla ME. Management of Penicillin Allergy in the Perioperative Setting. Antibiotics (Basel) 2024; 13:157. [PMID: 38391543 PMCID: PMC10886174 DOI: 10.3390/antibiotics13020157] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2023] [Revised: 01/22/2024] [Accepted: 01/23/2024] [Indexed: 02/24/2024] Open
Abstract
The selection of perioperative antibiotic prophylaxis is challenging in patients with a history of penicillin allergy; as such, we present a literature review exploring current best practices and the associated supporting evidence, as well as areas for future research. Guidelines recommend the use of alternative agents in patients with an IgE-mediated hypersensitivity reaction, but those alternative agents are associated with worse outcomes, including an increased risk of surgical site infection, and higher cost. More recent data suggest that the risk of cross-reactivity between penicillins and cephalosporins, particularly cefazolin, is extremely low, and that cefazolin can be used safely in most penicillin-allergic patients. Studies have therefore explored how best to implement first-line cefazolin use in patients with a penicillin allergy label. A variety of interventions, including preoperative allergy de-labeling with incorporation of penicillin skin testing, use of patient risk-stratification questionnaires, and utilization of clinician algorithms to guide antibiotic selection intraoperatively, have all been shown to significantly increase cefazolin utilization without a corresponding increase in adverse events. Further studies are needed to clarify the most effective interventions and implementation strategies, as well as to evaluate whether patients with severe delayed hypersensitivity reactions to penicillin should continue to be excluded from receipt of other beta-lactams.
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Affiliation(s)
- Mary Elizabeth Sexton
- Division of Infectious Diseases, Emory University School of Medicine, Atlanta, GA 30322, USA
| | - Merin Elizabeth Kuruvilla
- Department of Internal Medicine, Emory University School of Medicine, Atlanta, GA 30322, USA
- Novartis Pharmaceuticals, East Hanover, NJ 07936, USA
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He K, Dawson M, Stroh C, Taylor KM, Quigley S, Jones S, Cramm SL, Rangel SJ. A Process Improvement Project to Increase Compliance With Cephalosporin-based Surgical Antimicrobial Prophylaxis in Children With Non-severe Penicillin Allergies. J Pediatr Surg 2024; 59:61-67. [PMID: 37839950 DOI: 10.1016/j.jpedsurg.2023.09.025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/22/2023] [Accepted: 09/07/2023] [Indexed: 10/17/2023]
Abstract
BACKGROUND/PURPOSE Cephalosporins are considered safe and first-line prophylaxis in children with non-severe penicillin allergies. However, use of second-line agents is common and is primarily driven by poor allergic response documentation and misunderstanding of cross-reactivity risk. The goal of this project was to improve compliance with cephalosporin prophylaxis through improved documentation and targeted educational efforts. METHODS A multidisciplinary working group including representatives from allergy, surgery, infectious disease, and pharmacy developed staged interventions to facilitate compliance with cephalosporin prophylaxis. These included: (1) caregiver outreach to clarify incomplete allergy documentation, (2) a decision-support algorithm for prophylaxis use in penicillin-allergic patients, (3) standardized educational resources for surgical faculty and rotating trainees, (4) email reminders with prophylaxis recommendations sent out prior to scheduled cases, and (5) EMR-based decision support during antibiotic ordering. Rates of complete allergy documentation and cephalosporin utilization were compared for general surgery procedures between a 12-month pre-intervention and 14-month post-intervention period. RESULTS 578 patients with penicillin allergies recorded in the EMR were included (301 pre-intervention and 277 post-intervention), 54.0% of which received prophylaxis. Compared to the pre-intervention period, complete documentation of allergic reactions increased from 57.1% to 84.2% (p < 0.001) following implementation of all interventions. Appropriate prophylaxis utilization increased from 34.5% to 88.5% following implementation of all interventions (p < 0.001), and evidence of a stepwise increase in appropriate utilization was evident with each intervention stage. Persistent compliance failures during the post-implementation period were most commonly associated with urgent and emergent add-on cases. No adverse events or allergic responses were reported before or after project implementation. CONCLUSIONS Compliance with cephalosporin prophylaxis significantly improved following a multidisciplinary effort targeting education, allergy documentation, and clinical support at the point of care. Ongoing efforts include postoperative audits within 24 h for noncompliant cases in order to identify barriers and improve compliance for urgent and emergent add-on cases. LEVEL OF EVIDENCE III. TYPE OF STUDY Prospective.
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Affiliation(s)
- Katherine He
- Department of Surgery, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - Michele Dawson
- Department of Surgery, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - Crystal Stroh
- Department of Surgery, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - Kristina M Taylor
- Department of Surgery, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - Susan Quigley
- Department of Surgery, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - Sarah Jones
- Department of Surgery, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - Shannon L Cramm
- Department of Surgery, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - Shawn J Rangel
- Department of Surgery, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA.
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Hitchcock AM, Kufel WD, Seabury RW, Steele JM. Impact of a Pharmacist-Conducted Preoperative Beta-Lactam Allergy Assessment on Perioperative Cefazolin Prescribing. J Pharm Pract 2023:8971900231214581. [PMID: 37931904 DOI: 10.1177/08971900231214581] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2023]
Abstract
Background: Cefazolin is guideline recommended for perioperative prophylaxis in orthopedic surgery. Despite its unique R1 side chain, cefazolin is often avoided in patients with beta-lactam allergy with concern for cross reactivity. Objectives: The primary outcome was the percentage of patients who received cefazolin perioperatively. Secondary outcomes included the percentage of patients with a beta-lactam allergy clarified following the telephone interview and clinical outcomes including acute kidney injury, surgical site infection, Clostridioides difficile infection, and re-admission at 30 and 90 days. Methods: This single-center, quasi-experimental study evaluated a pilot program in which a pharmacist phoned patients > 18 years of age with a scheduled orthopedic surgery and a documented beta-lactam allergy to assess their allergy preoperatively. Recommendations to use cefazolin were based on an algorithm. Patients were divided into pre- and post-intervention cohorts. Results: A total of 832 patients were screened for inclusion with 135 and 66 patients included in the pre- and post-intervention cohorts. No significant difference was identified in the primary outcome. In the post-intervention cohort, 62% had a beta-lactam reaction updated in the electronic medical record. Those with a beta-lactam allergy delabeled or made less severe were numerically more likely to receive cefazolin than those with an unchanged reaction or a reaction made more severe (95.2% vs 68% vs 65%). There were no differences in clinical outcomes between groups. Conclusion: A pharmacist-conducted preoperative beta-lactam allergy interview in adult patients undergoing elective orthopedic surgery improved beta-lactam allergy documentation but, did not result in increased utilization of cefazolin.
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Affiliation(s)
- Allison M Hitchcock
- Department of Pharmacy, State University of New York Upstate University Hospital, Syracuse, NY, USA
- Department of Pharmacy, University of Pittsburgh Medical Center Harrisburg, Harrisburg, PA, USA
| | - Wesley D Kufel
- Department of Pharmacy, State University of New York Upstate University Hospital, Syracuse, NY, USA
- Department of Pharmacy Practice, Binghamton University School of Pharmacy and Pharmaceutical Sciences, Binghamton, NY, USA
- Department of Medicine, State University of New York Upstate Medical University, Syracuse, NY, USA
| | - Robert W Seabury
- Department of Pharmacy, State University of New York Upstate University Hospital, Syracuse, NY, USA
- Department of Medicine, State University of New York Upstate Medical University, Syracuse, NY, USA
| | - Jeffrey M Steele
- Department of Pharmacy, State University of New York Upstate University Hospital, Syracuse, NY, USA
- Department of Medicine, State University of New York Upstate Medical University, Syracuse, NY, USA
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Advances in immunoglobulin E mediated antibiotic allergy. Curr Opin Pediatr 2022; 34:609-615. [PMID: 36036421 DOI: 10.1097/mop.0000000000001171] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
PURPOSE OF REVIEW The purpose of this review is to identify recent advances in our understanding and management of immunoglobulin E (IgE)-mediated antibiotic allergy. RECENT FINDINGS Antibiotics remain a leading cause of fatal anaphylaxis reported to the FDA. However, recent advances have defined the features of adult and pediatric patients without true IgE-mediated allergy or any mechanism of anaphylaxis when tested. This has created opportunities to use direct challenges to disprove these allergies at the point-of-care and improves antibiotic stewardship. Additional advances have highlighted cross-reactive structural considerations within classes of drugs, in particular the R1 side-chain of cephalosporins, that appear to drive true immune-mediated cross-reactivity. Further advances in risk-based approaches to skin testing, phenotyping, and re-exposure challenges are needed to standardize antibiotic allergy evaluation. SUMMARY Recent advances in defining true IgE-mediated drug allergy have helped to identify patients unlikely to be skin-test positive. In turn, this has identified patients who can skip skin testing and proceed to direct ingestion challenge using history risk-based approaches. The ability to identify the small number of patients with true IgE-mediated allergy and study their natural history over time, as well as the vast majority without true allergy will facilitate important and novel mechanistic discoveries.
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Otero JE, Brown TS, Courtney PM, Kamath AF, Nandi S, Fehring KA. What's New in Musculoskeletal Infection. J Bone Joint Surg Am 2022; 104:1228-1235. [PMID: 35700085 DOI: 10.2106/jbjs.22.00183] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Affiliation(s)
- Jesse E Otero
- OrthoCarolina Hip and Knee Center, Atrium Health Musculoskeletal Institute, Charlotte, North Carolina
| | - Timothy S Brown
- Department of Orthopedics and Sports, Houston Methodist Hospital, Houston, Texas
| | | | - Atul F Kamath
- Orthopaedic & Rheumatologic Institute, Cleveland Clinic, Cleveland, Ohio
| | - Sumon Nandi
- University of Maryland School of Medicine, Baltimore, Maryland
| | - Keith A Fehring
- OrthoCarolina Hip and Knee Center, Atrium Health Musculoskeletal Institute, Charlotte, North Carolina
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11
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Penicillin Allergy in Spine Surgery: Increased rates of sepsis, emergency room visits and readmission. World Neurosurg 2022; 162:e91-e98. [DOI: 10.1016/j.wneu.2022.02.079] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2021] [Revised: 02/16/2022] [Accepted: 02/17/2022] [Indexed: 11/22/2022]
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