Improving cefazolin use for surgical antimicrobial prophylaxis in patients with penicillin allergy labels

Authors:
Sara Ausman, Jason Beckermann, Christopher Huiras, FNU Shweta, Sarah Lessard

Body of Abstract:
Background

Use of beta-lactam (BL) antibiotics for surgical antibiotic prophylaxis (SAP) has been linked to better surgical outcomes, including reduced surgical site infections and less safety events like acute kidney injury. Patients with documented reactions to penicillin or cephalosporin antibiotics often receive non-BL antibiotics which are linked to more adverse events and delays in administration. Implementation of a new protocol supporting safety of cefazolin in patients with penicillin allergy labels (PwPALs) improves BL use in surgical and procedural prophylaxis.

Methods

A retrospective, pre-post analysis of SAP for PwPALs was performed in a multi-region healthcare system in Wisconsin. Adult and pediatric PwPALs were included if antibiotics were administered as surgical prophylaxis. Patients without documented penicillin allergy labels or antibiotic doses administered were excluded. Interventions were undertaken in a step-wise approach between January 2021 and December 2023 including electronic health record allergy module enhancements, algorithm development, and point-of-care guidance to surgical clinicians. The pre-intervention (Pre-I) group reflects antibiotic doses documented in 2020 while antibiotic administrations in 2024 were included in the post-intervention (Post-I) group. A secondary analysis of PwPALs documented as anaphylaxis was also completed.

Results

Overall, cefazolin use improved in PwPALs from 72.9% to 91.1% between 2020 and 2024 (844/1157 doses and 1362/1495 doses, respectively). Improvement in cefazolin prescribing was seen regardless of procedure category – clean versus clean-contaminated (Table 1). A corresponding decrease in vancomycin prescribing for PwPALs was observed across all procedure types from 8% (74/1157) of patients receiving in 2020 compared to 0.6% (9/1495) in 2024. Secondary analysis of PwPALs documented as anaphylaxis showed cefazolin use improved significantly from 36.2% (34/94 doses) pre-intervention to 88.2% (85/93 doses) post-intervention for all procedure types. Similar reduction in vancomycin doses was seen in the PwPAL documented as anaphylaxis (Pre-I: 27.7%, 26/94 doses vs. Post-I 2.2%, 2/93 doses). All post-intervention changes were statistically significant (Table 1). No difference in new cefazolin allergies added to EHR or anaphylaxis surrogate markers, including administration of rescue medications or tryptase orders, were observed in the Post-I cohort.

Conclusions

Use of cefazolin for surgical antimicrobial prophylaxis in patients with penicillin allergy labels, including reported anaphylaxis, is safe. Developing institutional protocols improves appropriate SAP choice in PwPALs.