Cefazolin may be safe option before surgery for patients with penicillin allergy labels
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None of the patients with a penicillin allergy label who received cefazolin before surgery experienced allergic symptoms related to the antibiotic, according to a study published in Annals of Allergy, Asthma & Immunology.
Patients with penicillin allergy labels (PALs) use cefazolin less frequently and are more likely to use alternative antibiotics, increasing surgical site infection risks, Jocelyn J. Cooper, MD, an internal medicine resident in the department of medicine at University of Washington, and colleagues wrote in the study.
The study queried the electronic medical records of 1,741 patients with PALs who had surgical procedures between Jan. 1 and Dec. 31, 2020, at University of Washington Medical Center.
Of these patients, 549 (white, 77.2%; women, 61.9%) used cefazolin before their surgery. Their PALs included all penicillin (52.3%), amoxicillin (28.6%) or amoxicillin-clavulanate (13.8%), with some PALs including multiple types of penicillin.
Also, 427 of these patients (77.8%) had documented index reactions, including rash (40%), gastrointestinal upset (25.3%), hives (20.6%), respiratory distress (1.9%), anaphylaxis (1.2%) and angioedema (0.7%).
However, 544 (99.1%) of the patients with PAL who received cefazolin had no documented postoperative allergic-type reaction, and the researchers did not consider the reactions in the five remaining patients to be related to the cefazolin.
Two of these patients had index reactions of rash and developed postoperative pruritis 4 hours after receiving cefazolin, which the researchers attributed to opioid medication. The third patient had index reactions of rash and hives and had intraoperative anaphylaxis 3 hours after the cefazolin dose.
The fourth patient had an index reaction of rash and developed postoperative pruritus, although there was no immediate reaction when cefazolin was administered 2.5 hours earlier, and the researchers listed the cause of this reaction as unknown.
The final patient had an index reaction of rash with intraoperative anaphylaxis 15 minutes after receiving cefazolin. Skin testing for cefazolin and penicillin during outpatient evaluation was negative, but it was positive for rocuronium, which the patient received immediately before the reaction.
Based on these findings, the researchers said that patients with a PAL could safely use cefazolin prophylactically before surgery. Also, the researchers plan to develop educational and clinical tools for making decisions to encourage doctors to use cefazolin in patients with PAL.
Perspective
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This study is very much in line of what we’ve seen in other studies. The data are very reassuring regarding the extremely low likelihood of a patient with a penicillin allergy label having an issue with preoperative cefazolin. In fact, Kaiser Permanente has gone as far as to remove the cross-reactivity warning from its electronic health record.
This letter adds to the data that cefazolin should be given to the vast majority of patients with a penicillin allergy label for preoperative prophylaxis. There is even a study that demonstrates shorter operative room time among patients with penicillin allergy if cefazolin is used compared with vancomycin, and we know that beta-lactams such as cefazolin are superior preoperative prophylaxis.
Reference:
Moussa Y, et al. Surgery. 2018;doi:10.1016/j.surg.2018.03.004.
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