The Effect of a Penicillin Allergy Algorithm on Perioperative Antibiotic Choice

Rationale: Cephalosporins are the preferred medications for perioperative antimicrobial prophylaxis. Due to the potential risk of cross-reactivity between penicillins and cephalosporins, alternatives such as clindamycin are often administered to patients who report penicillin allergy. Clindamycin has potential to cause adverse hemodynamic effects when used in the perioperative setting, and lacks gram negative coverage. 

Methods: The Nemours/A.I. duPont Hospital for Children developed an algorithm to evaluate penicillin allergic patients who present to the operating room. The algorithm recommends use of cephalosporins in select patients based on the clinical history of the penicillin reaction. The perioperative antibiotics administered to penicillin allergic patients who were screened using the protocol from May to June of 2015 were compared to a historical cohort from May to June of 2014. 

Results: Fifty-four penicillin allergic patients (male to female ratio of 1:1) were screened using the algorithm. There were 46 penicillin allergic patients (male to female ratio of 2:3) in the pre-intervention group. When the algorithm was employed, clindamycin use decreased from 32.6% (15/46) to 9.3% (5/54) and the use of 1^st or 2^ndgeneration cephalosporins increased from 67.3% (31/46) to 88.8% (48/54).  

Conclusions: In the preoperative setting, a penicillin allergy algorithm increased cephalosporin and decreased clindamycin use. Preoperative penicillin skin testing for penicillin allergy has also been shown to increase the use of cephalosporins, however, skin testing in this setting may not always be practical. A penicillin allergy algorithm is an effective and efficient screening tool that could be expanded institution-wide and implemented at other tertiary care centers.