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Improving Antibiotic Stewardship
By:Yara Moussa
Published on 2019 by

|Approximately 10% of individuals claim penicillin allergy based on vague or remote histories and are permanently labeled [beta]-lactam allergic. These individuals receive suboptimal non-[beta]-lactams for intraoperative prophylaxis prolonging operations and experience negative clinical outcomes. Clarifying penicillin allergic status is thus of major importance. This thesis examines pre-operative allergy assessments including drug allergic history, penicillin skin testing and/or oral challenge on selection of perioperative antibiotics. It also examines the effectiveness of communicating the drug allergy patient de-labeling status to the surgical team. Patients referred from April 1st, 2015 to March 31st, 2017 for suspected [beta]-lactam hypersensitivity were studied. Those having pre-operative allergy assessments within 6 months of surgery were analysed. Data collected included age, gender, drug allergy history, drug allergy skin testing, oral challenges along with the type of surgery, time of operating room entry, incision start time and intraoperative antibiotics.. Of the 194 patients evaluated, four were [beta]-lactam allergic on skin testing. Among the remaining 190 skin test negative patients, 146 were [beta]-lactam challenged. Only 5% of these reacted and considered [beta]-lactam allergic. Cefazolin became the perioperative antibiotic of choice for the remaining 77% of non-allergic patients requiring antibiotic prophylaxis. Only 5 of the confirmed [beta]-lactam allergic patients received intraoperative vancomycin. Patients not prescribed vancomycin saved on average 22 minutes in operative time. Among all 194 evaluated patients, 35 were given suboptimal alternative antibiotics perioperatively. These included 16 that tested negative for [beta]-lactam allergy yet prescribed vancomycin and 17 that received clindamycin. The 2 remaining tested positive for [beta]-lactam allergy and were erroneously given cefazolin. The suboptimal antibiotic use stemmed from poor reporting of the allergy evaluations. Factors included delays in transmitting the results from the allergy clinic in 12 patients, 15 patients reported being [beta]-lactam allergic to the surgical team at the time of surgery despite having tested negative and the remaining 8 had no clear reason for being prescribed an alternative antibiotic. To identify causes of miscommunication, a questionnaire survey was sent to allergists, surgeons and anesthesiologists.. Results of the survey revealed that surgeons and anesthesiologists prefer direct and clear statements like |the patient is not allergic to penicillin| or |can be administered cefazolin|; while allergists preferred qualifying statements such as |at this time the patient is not allergic to penicillin, based on skin testing, oral challenge and clinical assessment|. In summary, comprehensive penicillin allergy evaluation successfully de-labeled 94.3% of patients referred for pre-operative [beta]-lactam allergy evaluation. Vancomycin was used only in five surgeries (3%) (those truly penicillin allergic) and cefazolin was subsequently prescribed for 120/155 (77.4%) of the de-labeled patients given antibiotics.. The reduced use of vancomycin minimized delays in initiation of incision time, thus improving operative efficiency. Multiple issues indicating poor communication were identified partially explaining the suboptimal antibiotic use and signifying a need for consensus statements in drug allergy reporting. The main limitation of the study was that pre-operative allergy referrals were not mandatory, thus not all pre-operative patients claiming to be [beta]-lactam allergic were captured.| --

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