Infection Control & Hospital Epidemiology (2018), 39, 1480–1483 doi:10.1017/ice.2018.244


Concise Communication


Variability of surgical prophylaxis in penicillin-allergic children David F. Butler MD1,†, Brian R. Lee MPH, PhD1, Sarah Suppes PharmD2, Tracy Sandritter PharmD2,


Jason G. Newland MD, M.Ed3, Lory Harte PharmD2 and Jennifer L. Goldman MD, MS1 1Department of Pediatrics, Children’s Mercy Hospital, Kansas City, Missouri, 2Department of Pharmacy, Children’s Mercy Hospital, Kansas City, Missouri and 3Department of Pediatrics, Washington University School of Medicine, St Louis, Missouri


Abstract


We retrospectively evaluated the effect of penicillin adverse drug reaction (ADR) labeling on surgical antibiotic prophylaxis. Cefazolin was administered in 86% of penicillin ADR-negative (−) and 28% penicillin ADR-positive (+) cases. Broad-spectrum antibiotic use was more common in ADR(+) cases and was more commonly associated with perioperative adverse drug events.


(Received 21 March 2018; accepted 19 August 2018)


surgical site infections (SSIs) in high-risk pediatric procedures.5,6 Cefazolin is the drug of choice for many procedures because it is bactericidal, rapidly infused/distributed, and covers skin patho- gens such as Staphylococcus aureus associated with SSIs.5,6 While structurally similar to penicillin due to the β-lactam ring, different side chains result in minimal cross reactivity. Only patients who experience an IgE-mediated response (eg, anaphylaxis) or a severe cutaneous reaction (eg, Stevens-Johnson syndrome) to penicillin should avoid future cephalosporins.5 The primary objective of our study was to determine antibiotic prophylaxis selection in pediatric surgical patients with a documented penicillin ADR. Secondarily, we aimed to determine the antibiotic prophylaxis most commonly associated with perioperative adverse drug events (ADEs).


Approximately 10% of patients have a documented penicillin allergy, although the incidence of a true allergic reaction is much less frequent.1 A penicillin adverse drug reaction (ADR) label is associated with the unnecessary use of broad-spectrum anti- biotics, prolonged hospitalization, increased prevalence of multidrug-resistant infections, and increased risk of death com- pared to those without a penicillin ADR label.2–4 ADRs may refer to allergic reactions (eg, rash or anaphylaxis) or side effects (eg, diarrhea). Unfortunately, clinicians often fail to obtain a thorough ADR history or to clarify the type of reported reaction prior to prescribing medication.2,3 Antibiotic prophylaxis is utilized routinely to reduce the risk of


Authors for correspondence: David F. Butler, MD, Division of Pediatric Critical Care


Medicine, Department of Pediatrics, Seattle Children’s Hospital, University of Washington School of Medicine, FA.2.112, 4800 Sand PointWay NE, Seattle WA 98105. E-mail: david.butler@seattlechildrens.org. Also, Jennifer Goldman MD, MS Divisions of Pediatric Infectious Diseases & Clinical Pharmacology, Department of Pediatrics, Children’s Mercy Hospital, 2401 Gillham Rd, Kansas City, MO 64108. E-mail:


jlgoldman@cmh.edu † Present affiliation: Division of Pediatric Critical Care, University of Washington, Seattle Children’s Hospital, Seattle, Washington.


Cite this article: Butler DF et al. (2018). Variability of surgical prophylaxis in


penicillin-allergic children. Infection Control & Hospital Epidemiology 2018, 39, 1480– 1483. doi: 10.1017/ice.2018.244


© 2018 by The Society for Healthcare Epidemiology of America. All rights reserved.


Materials and methods Population and setting


Aretrospective study was performed extracting data froma surgical bundle reliability report for the period from January 1, 2011, to December 31, 2013. The surgical bundle reliability report is gener- ated from the hospital electronic medical records as a part of a national quality improvement collaborative. All operating room procedures lasting >5 minutes are included in the report. For this study, only patients who received at least 1 dose of an intraoperative antibiotic were included. The data collected included age, race, gender, surgery month/year, surgical procedure, isolation status (ie, evidence of methicillin-resistant S. aureus (MRSA) carrier status), wound class (ie, clean, clean/contaminated, contaminated, dirty/ infected), and antibiotic(s) administered during surgery. The Chil- dren’sMercy Institutional Review Board approved this protocol.


Penicillin ADR label


Penicillin ADR type was defined as allergy or hypersensitivity or side effect, and severity was defined as follows: mild, implicated drug continued; moderate, implicated drug discontinued and/or ADR treatment required; and severe, life-threatening or need for hospitalization. ADR type and severity data were available in the electronic medical record (EMR) at the time of surgery. These data are readily available to prescribers; however, attention to this qualifier is user dependent and likely variable. Documentation of penicillin ADRs included any of the following antibiotics: amoxicillin, oxacillin, penicillin, amoxicillin-clavulanate, ampi- cillin, ampicillin-sulbactam, piperacillin-tazobactam. Patients with a penicillin allergy or hypersensitivity but undocumented severity were included as ‘unknown’ severity. Patients with a documented cephalosporin ADR were excluded.


Potential perioperative adverse drug event (ADE)


Potential perioperative ADEs were based on International Clas- sification of Diseases, Ninth Revision, Clinical Modification


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