Leveraging Quality Improvement to Enhance First-Line Surgical Antibiotic Prophylaxis in Penicillin-Allergic Patients
David Buck MD, MBA, Lynn Martin MD, MBA
There are many old wive’s tales (bubba meisas) that have serious implications in how we practice pediatric anesthesia, like the 2 hour clear liquid NPO time before the induction of anesthesia, cricoid pressure during rapid sequence inductions, and the avoidance of cephalosporins for surgical site infection prophylaxis in penicillin allergic patients. We’ve discussed the cefazolin and penicillin allergy bubba meisa in previous PAADs (May 08, 2022 https://ronlitman.substack.com/p/cephazolin-and-penicillin-allergy ). A consistent theme in our recent PAADs is how to translate and implement change. In today’s PAAD, our quality and safety and implementation science team will review one institution’s approach to using cefazolin in penicillin allergic patients. Myron Yaster MD
A drug allergy is an allergic reaction to a medication in which the body’s immune system mistakenly identifies a drug as a harmful substance, triggering a release of chemicals which cause the symptoms we recognize as an allergic reaction (i.e., rash, itching, hives, wheezing, and anaphylaxis in severe cases). Repeat exposures elevates the risks for adverse outcomes. Typically, clinicians will opt for the lowest risk approach. Today’s PAAD is a great example of this. Patients are not receiving appropriate first-line surgical antibiotic prophylaxis due to fear of an allergic cross reaction. David Buck MD, MBA & Lynn Martin MD, MBA.
Original Article
Mock M, Morris D, Foley J, et al. Leveraging Quality Improvement Tools to Improve Administration of First-line Surgical Antibiotic Prophylaxis in Patients Labeled as Penicillin Allergic. Pediatr Qual Saf. Jan-Feb 2025;10(1):e794. doi:10.1097/pq9.0000000000000794. PMID: 39850064.
Introduction: Reducing surgical site infections (SSIs) is crucial for improving patient outcomes, shortening hospital stays, and lowering healthcare costs. However, many hospitals face challenges in effectively reducing SSIs. Effective collaboration among anesthesia, surgery, and pharmacy teams on proper surgical antibiotic prophylaxis (SAP) antibiotic administration is an integral part of this process, especially in patients with a reported penicillin allergy. This article describes a quality improvement project to increase the use of first-line SAP agents in pediatric orthopedic and pediatric surgery patients with a reported penicillin allergy.1 It presents a collaborative project that offers a blueprint for improving antibiotic administration processes in our institutions.
Why It Matters: Approximately 2-4% of patients undergoing surgery experience an SSI2. Cephalosporins and other beta-lactam antibiotics are known to be the most effective in preventing SSIs, making them the first-line choice for SAP. However, patients with a reported penicillin allergy are less likely to receive a first-line SAP and are, therefore, at increased SSI risk. Though penicillin allergies are reported in 10% of patients, more than 90% oh those may not have a true allergy.3 While cephalosporins are structurally related to penicillin (they both contain a beta-lactam ring), studies indicate that the risk of cross-reactivity is much lower (about 1%) than the traditionally cited rate of 10%. Even in patients with a confirmed penicillin allergy is about 2.5%.4 A comprehensive and multifaceted approach is needed to increase use of first-line SAP in patients with a reported penicillin allergy in an effort to decrease the risk of SSIs.
What They Did: The team implemented a collaborative, multifaceted strategy involving surgery, nurse practitioners, and pharmacy, utilizing the Institute for Healthcare Improvement quality improvement methodology. Key drivers included (a) family awareness of true penicillin allergies, (b) standardized antibiotic ordering practices, (c) staff buy-in, (d) electronic medical record (EMR) utilization, and (e) staff comfort with ordering first-line SAP.
Key interventions included:
· Education: Providing training for surgeons, anesthesiologists, nurse practitioners, and perioperative staff.
· Screening Tools: Developing a standardized tool for identifying true severe delayed hypersensitivity reactions (SDHR).
· EMR Updates: Updated guidelines incorporated into the EMR.
· Transparency: Sharing outcomes openly with healthcare teams.
· Resources: Distributing laminated pocket cards for residents.
Additionally, a screening process was established to identify patients who genuinely need to avoid cephalosporins.
What They Found:
· Increased First-Line Antibiotic Use: The percentage of penicillin-allergic patients receiving first-line antibiotics rose from 25% to 84%.
· Safety: No adverse reactions were reported.
· SSIs: While there was no statistically significant change in SSIs, a gradual decrease in institutional SSI rates was observed during the study. This is likely due to the rarity of the infections and the single center study.
· Sustainability: These improvements were maintained over nine months. I (LDM) think the true test will come when the new practice has been sustained across resident classes.
Key Takeaways:
· Framework for Improvement: The approach outlined in this paper provides a structured method for managing patients with penicillin allergies.
· Starting Point: Assess the percentage of penicillin-allergic patients in your department who receive first-line antibiotics.
· Multidisciplinary Approach: Successful Improvement necessitates education, standardization, transparency, and EMR modifications.
· Screening Tool: Include a tool for identifying true SDHR.
· Ongoing Monitoring: Continuous monitoring is essential for maintaining improvements.
What is going on in your practice? Could your center follow a similar improvement effort to reduce the risk of SSI? Send your thoughts and comments to Myron who will post in a Friday reader response.
References
1. Mock M, Morris D, Foley J, et al. Leveraging Quality Improvement Tools to Improve Administration of First-line Surgical Antibiotic Prophylaxis in Patients Labeled as Penicillin Allergic. Pediatr Qual Saf. Jan-Feb 2025;10(1):e794. doi:10.1097/pq9.0000000000000794. PMID: 39850064.
2. PSNet. Surgical site infections. Accessed April 8, 2024. https://psnet.ahrq.gov/primer/surgical-site-infections
3. Shenoy ES, Macy E, Rowe T, Blumenthal KG. Evaluation and Management of Penicillin Allergy: A Review. JAMA. Jan 15 2019;321(2):188-199. doi:10.1001/jama.2018.19283. PMID: 31211341.
4. Campagna JD, Bond MC, Schabelman E, Hayes BD. The use of cephalosporins in penicillin-allergic patients: a literature review. J Emerg Med. May 2012;42(5):612-20. doi:10.1016/j.jemermed.2011.05.035. PMID: 21742459.