These authors assessed the effectiveness of a simple, protocol-driven penicillin allergy screening program to predict the safety of administering cephalosporins to patients with a history of allergic reaction to penicillin.
Patients scheduled having primary total joint arthroplasty were risk-stratified into low or high-risk categories based on the criteria below:
The low-risk cohort received cefazolin, and the high-risk cohort received non-cefazolin antibiotics.
The study group (n = 2,078) was propensity score matched 1:1 with a control group that included patients who underwent TJA in the same institution prior to implementation of the protocol.
A total of 357 patients (17.2%) reported a penicillin allergy in the study group compared with 310 patients (14.9%) with a recorded allergy in the control group.
The allergy history of the patients in the study group is shown below
The number of patients who received non-cephalosporin antibiotics was significantly lower in the study group (5.7% compared with 15.2% in the control group).
There was no difference in the rate of total allergic reactions (0.8% compared with 0.7%.
Of the 239 low-risk patients (66.9%) in the study group, only 3 (1.3%) experienced a mild cutaneous reaction following cefazolin administration.
There were no differences in the rates of superficial wound, deep periprosthetic, or Clostridioides difficile infections between the protocol and control groups.
Thus the screening protocol allowed two-thirds of patients with a self-reported allergy to receive cefazolin without the need for additional consultations or testing; the overall rate of cefazolin usage
increased by 9%, to 94%, without an increase in adverse reactions.
The authors' protocol includes amending the medical record to indicate safe administration of cephalosporin as shown below
Comment: These data are of great importance to shoulder arthroplasty surgeons and their patients. Cutibacterium is the organism that causes most shoulder periprosthetic infections. Cephalosporins appear to be the antibiotic most effective against Cutibacterium. While Clindamycin is often used as prophylaxis in patients thought to be allergic to penicillin, over 25% of Cutibacterium have been found to be resistant to Clindamycin (see this link).
As the authors point out, when tolerance of cephalosporins is observed, it is important to amend the medical record to so indicate.
Another particularly informative article on this subject is Evaluation and Management of Penicillin Allergy A Review The abstract is reproduced below:
IMPORTANCE β-Lactam antibiotics are among the safest and most effective antibiotics. Many patients report allergies to these drugs that limit their use, resulting in the use of broad-spectrum antibiotics that increase the risk for antimicrobial resistance and adverse events.
OBSERVATIONS Approximately 10% of the US population has reported allergies to the β-lactam agent penicillin, with higher rates reported by older and hospitalized patients. Although many patients report that they are allergic to penicillin, clinically significant IgE-mediated or T lymphocyte–mediated penicillin hypersensitivity is uncommon (<5%). Currently, the rate of IgE-mediated penicillin allergies is decreasing, potentially due to a decreased use of parenteral penicillins, and because severe anaphylactic reactions to oral amoxicillin are rare. IgE-mediated penicillin allergy wanes over time, with 80% of patients becoming tolerant after a decade. Cross-reactivity between penicillin and cephalosporin drugs occurs in about 2%of cases, less than the 8%reported previously. Some patients have a medical history that suggests they are at a low risk for developing an allergic reaction to penicillin. Low-risk histories include patients having isolated nonallergic symptoms, such as gastrointestinal symptoms, or patients solely with a family history of a penicillin allergy, symptoms of pruritus without rash, or remote (>10 years) unknown reactions without features suggestive of an IgE-mediated reaction. A moderate-risk history includes urticaria or other pruritic rashes and reactions with features of IgE-mediated reactions. A high-risk history includes patients who have had anaphylaxis, positive penicillin skin testing, recurrent penicillin reactions, or hypersensitivities to multiple β-lactam antibiotics. The goals of antimicrobial stewardship are undermined when reported allergy to penicillin leads to the use of broad-spectrum antibiotics that increase the risk for antimicrobial resistance, including increased risk of methicillin-resistant Staphylococcus aureus and vancomycin-resistant Enterococcus. Broad-spectrum antimicrobial agents also increase the risk of developing Clostridium difficile (also known as Clostridioides difficile) infection. Direct amoxicillin challenge is appropriate for patients with low-risk allergy histories. Moderate-risk patients can be evaluated with penicillin skin testing, which carries a negative predictive value that exceeds 95%and approaches 100% when combined with amoxicillin challenge. Clinicians performing penicillin allergy evaluation need to identify what methods are supported by their available resources.
CONCLUSIONS AND RELEVANCE Many patients report they are allergic to penicillin but few have clinically significant reactions. Evaluation of penicillin allergy before deciding not to use penicillin or other β-lactam antibiotics is an important tool for antimicrobial stewardship.
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Here are some videos that are of shoulder interest
