Cefazolin for All: Improving Surgical Infection Prevention Through Safe Antimicrobial Stewardship

Authors:
Yeshwanth Vedire, Drishti Lall, Mohammad Maki, Abigail Ruby, Eman Chami, Anita Shallal, Arielle Hodari Gupta

Body of Abstract:
Introduction: Surgical site infections (SSI) account for almost 20% of all hospital acquired infections, increase hospital length of stay by nearly 10 days and increase cost by $20,000 per admission. There is a reported 50% increase in SSI rate in patients with reported penicillin allergies due to the use of alternative non-beta-lactam antibiotics instead of cefazolin, despite evidence on consensus guidelines suggesting its safety in these cases. We sought to describe the impact of an educational campaign to improve cefazolin prescribing for surgical infection prophylaxis (SIP) at our institution.

Methods: This was an IRB exempt, single pre-test, post-test quasi-experiment at our single institution in southeast Michigan. Beginning in late February 2025, interventions included revising surgical order sets to clearly state cefazolin safety in penicillin allergic patients, updating institutional guidelines for both allergy and SIP to restrict alternative non-beta-lactam antibiotics to cases of type IV mediated hypersensitivity reactions (ie; severe cutaneous adverse reactions [SCAR] such as Steven Johnson Syndrome [SJS[, Toxic Epidermal Necrolysis [TEN], Drug Reaction with Eosinophilia and Systemic Symptoms [DRESS], Acute Generalized Exanthematous Pustulosis [AGEP]), modifying electronic medical records of documented allergies to more clearly delineate severity and separate rash from SCAR, and creation of a cefazolin prescribing dashboard to monitor trends. An extensive educational campaign was launched, featuring interactive materials, QR-accessible slides with knowledge checks, educational flyers, and default workstation screensavers in preoperative areas. Additionally, anesthesia, surgical and orthopedic grand rounds reinforced education and promoted practice change. The primary endpoint was the proportion of outpatients receiving cefazolin for NHSN procedures (colectomies, hysterectomies, C sections, spinal fusions, hip and knee arthroplasties) in the pre-intervention (Sept 2024-Feb 2025) and post-intervention (April 2025-Sept 2025).

Results: 62.6% of patients received cefazolin in the 6 months preceding the intervention compared to 70.2% on average in the 6 months after, representing an absolute increase of 7.6%. This improvement in cefazolin compliance is observed in outpatient surgeries (84.3% vs. 93.4%) and admissions following a surgery (68.8% vs. 79%). Despite an increase in cefazolin use, there was no significant decrease in SSI rate since project implementation (2.7% vs. 2%).

Conclusion: By using a combination of EMR order sets, extensive educational campaigns, and visual reminders, we have shown that the “Cefazolin for All” campaign improved cefazolin use, promoting evidence-based practices and improving surgical infection prevention and antimicrobial stewardship. Although a significant decrease in SSI rate has not yet been observed, ongoing monitoring to evaluate the long term impact on patient outcomes is needed.