Today’s Pediatric Anesthesia Article of the Day is on a subject close to my heart: perioperative antibiotic prophylaxis. Is it safe to use cefazolin in patients labelled with a penicillin allergy? I’ve asked Jay Deshpande, an expert in quality improvement and safety to join our PAAD editorial council and today’s article is his maiden voyage. For those unfortunate few who don’t know him, Jay was a former president of the Society for Pediatric Anesthesia and a Robert M. Smith award winner. Hopefully you will see more PAADs by Jay in the coming months. Myron Yaster MD
Original article
Isserman RS, Cheung J, Varallo D, Cafone J, Lee J, Chiotos K, Muhly WT, Metjian TA, Swami S, Baldwin K, Tan JM. Increasing Cefazolin Use for Perioperative Antibiotic Prophylaxis in Penicillin-Allergic Children. Pediatrics. 2022 Mar 1;149(3):e2021050694. doi: 10.1542/peds.2021-050694. PMID: 35229120
Because of its good activity against skin flora, cefazolin (Ancef™), a first-generation cephalosporin, is the most common antibiotic recommended for perioperative antibiotic prophylaxis. Unfortunately, the use of cefazolin has been hampered by the reluctance of some providers to administer it in the setting of a patient with a reported penicillin allergy.(1,2) “Penicillin allergies are the most common drug allergy in the United States. However, only 10% of patients labeled with a penicillin allergy have true immunoglobulin E–mediated hypersensitivity reactions. Most hypersensitivity reactions to cephalosporins are due to R-group side chains rather than the β-lactam ring that is common to penicillin and cephalosporins. Cefazolin does not share any R-group side chains with penicillins, making cross-reactivity extremely unlikely.”(1) Once a penicillin allergy label is applied, it is often perpetuated throughout childhood and into adulthood, leading to a lifetime avoidance of the penicillin class of antibiotics.”(1,3) For patients with a reported penicillin allergy, alternative antibiotics, such as clindamycin or vancomycin, are frequently administered in place of cefazolin for perioperative antibiotic prophylaxis but they aren’t as effective (increased surgical site infections) and are more expensive.(4-6)
The goal of this quality improvement (QI) project was to increase the use of cefazolin in patients with non-severe penicillin allergies who most likely should receive cefazolin for perioperative prophylaxis. The “QI team consisted of 3 anesthesiologists, an infectious disease physician, two allergy and immunology physicians, two members of the Antimicrobial Stewardship Program (ASP), a pharmacist, and a surgeon. The team was supported by a QI project advisor and a data analyst. The team planned to use iterative plan-do-study-act (PDSA) cycles to achieve their specific, measurable, achievable, relevant, and time-bound aim”.
The upshot? Over a 3 year period, the number of patients with non-severe penicillin allergy treated with cefazolin increased from 41% to 90%, a truly remarkable achievement made possible by “education and multidisciplinary cooperation.”(1) They had no cases of severe allergic reactions in the operating room. The paper nicely describes effective use of QI tools, including control charts to show the impact of various interventions. The authors note that their success was possible because at the Children’s Hospital of Philadelphia (CHOP) where the study was performed, antibiotic prophylaxis orders are written by the anesthesia care team. Similar success may be more challenging to achieve in institutions in which the surgeons write these orders.
There are many “vampire” myths that guide our practice (just think NPO fasting times, preoxygenating with 100% FiO2 instead of 80%) that are hard to kill. This is another.
References
1. Isserman RS, Cheung J, Varallo D, Cafone J, Lee J, Chiotos K, Muhly WT, Metjian TA, Swami S, Baldwin K, Tan JM. Increasing Cefazolin Use for Perioperative Antibiotic Prophylaxis in Penicillin-Allergic Children. Pediatrics 2022;149.
2. Vorobeichik L, Weber EA, Tarshis J. Misconceptions Surrounding Penicillin Allergy: Implications for Anesthesiologists. Anesth Analg 2018;127:642-9.
3. Vyles D, Antoon JW, Norton A, Stone CA, Jr., Trubiano J, Radowicz A, Phillips EJ. Children with reported penicillin allergy: Public health impact and safety of delabeling. Ann Allergy Asthma Immunol 2020;124:558-65.
4. Butler DF, Lee BR, Suppes S, Sandritter T, Newland JG, Harte L, Goldman JL. Variability of surgical prophylaxis in penicillin-allergic children. Infect Control Hosp Epidemiol 2018;39:1480-3.
5. Blumenthal KG, Ryan EE, Li Y, Lee H, Kuhlen JL, Shenoy ES. The Impact of a Reported Penicillin Allergy on Surgical Site Infection Risk. Clin Infect Dis 2018;66:329-36.
6. Blumenthal KG, Shenoy ES, Varughese CA, Hurwitz S, Hooper DC, Banerji A. Impact of a clinical guideline for prescribing antibiotics to inpatients reporting penicillin or cephalosporin allergy. Ann Allergy Asthma Immunol 2015;115:294-300.e2.
[JD1]MY – not sure if this is misplaced or we are missing a quotation mark?