Dataset Information

Increasing cefazolin use for surgical prophylaxis in penicillin-allergy-labeled patients.

ABSTRACT:

Objective

Penicillin (PCN) allergy labels affect antimicrobial selection for surgical prophylaxis. We aimed to increase the percentage of cefazolin usage in patients with PCN allergy labels undergoing orthopedic surgery from 50% to 80%.

Design

Quality improvement initiative.

Setting

Children's Mercy Kansas City (CMKC), a freestanding children's hospital.

Patients

Children scheduled for an orthopedic surgery (excluding spinal surgery) at CMKC who had a PCN allergy label and received a perioperative antibiotic.

Methods

No standardized process existed to identify and clarify PCN-allergic-labeled patients preoperatively. We developed a process for patient identification combined with a pharmacist phone interview for PCN allergy clarification. In plan-do-study-act (PDSA) part 1, we implemented a computer-generated patient list. In PDSA part 2, we combined automated identification with a phone interview. In PDSA part 3, we enhanced the patient list, making it timely and concise. In PDSA part 4, we included a PCN allergy clarification electronic survey to caregivers via the electronic medical record.

Results

Cefazolin use in PCN-allergic surgical patients increased from 50% to 74% following interventions. Patients who had their PCN allergy label clarified were 4 times more likely to receive cefazolin compared to those whose allergy labels were not clarified (OR, 4.21; 95% CI, 1.68-11.61; P = 0.003). Moreover, 90% of patients received cefazolin when their PCN allergy was clarified and cefazolin was recommended. When a PCN allergy label was not clarified, only 59% of patients received cefazolin.

Conclusions

Appropriate clarification and documentation of PCN allergy labels increases the use of cefazolin for surgical prophylaxis.

SUBMITTER: VanderVelde KA

PROVIDER: S-EPMC9879898 | biostudies-literature | 2023

REPOSITORIES: biostudies-literature

ACCESS DATA

Publications

Increasing cefazolin use for surgical prophylaxis in penicillin-allergy-labeled patients.

VanderVelde Kathryn A KA Suppes Sarah L SL Gibbs Katherine A KA Latz Kevin H KH Vanderpool Angela C AC El Feghaly Rana E RE Goldman Jennifer L JL

Antimicrobial stewardship & healthcare epidemiology : ASHE 20230111 1

<h4>Objective</h4>Penicillin (PCN) allergy labels affect antimicrobial selection for surgical prophylaxis. We aimed to increase the percentage of cefazolin usage in patients with PCN allergy labels undergoing orthopedic surgery from 50% to 80%.<h4>Design</h4>Quality improvement initiative.<h4>Setting</h4>Children's Mercy Kansas City (CMKC), a freestanding children's hospital.<h4>Patients</h4>Children scheduled for an orthopedic surgery (excluding spinal surgery) at CMKC who had a PCN allergy lab ...[more]

PMID: 36714293

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Project description:Introduction:Resistant Gram-positive organisms, such as methicillin-resistant staphylococci, account for a significant proportion of infections following joint replacement surgery. Current surgical antimicrobial prophylaxis guidelines recommend the use of first-generation or second-generation cephalosporin antibiotics, such as cefazolin. Cefazolin, however, does not prevent infections due to these resistant organisms; therefore, new prevention strategies need to be examined. One proposed strategy is to combine a glycopeptide antibiotic with cefazolin for prophylaxis. The clinical benefit and cost-effectiveness of this combination therapy compared with usual therapy, however, have not been established.Methods and analysis:This randomised, double-blind, parallel, superiority, placebo-controlled, phase 4 trial will compare the incidence of all surgical site infections (SSIs) including superficial, deep and organ/space (prosthetic joint) infections, safety and cost-effectiveness of surgical prophylaxis with cefazolin plus vancomycin to that with cefazolin plus placebo. The study will be performed in patients undergoing joint replacement surgery. In the microbiological sub-studies, we will examine the incidence of SSIs in participants with preoperative staphylococci colonisation (Sub-Study 1) and incidence of VRE acquisition (Sub-Study 2). The trial will recruit 4450 participants over a 4-year period across 13 orthopaedic centres in Australia. The primary outcome is the incidence of SSI at 90 days post index surgery. Secondary outcomes include the incidence of SSI according to joint and microorganism and other healthcare associated infections. Safety endpoints include the incidence of acute kidney injury, hypersensitivity reactions and all-cause mortality. The primary and secondary analysis will be a modified intention-to-treat analysis consisting of all randomised participants who undergo eligible surgery. We will also perform a per-protocol analysis.Ethics and dissemination:The study protocol was reviewed and approved by The Alfred Hospital Human Research Ethics Committee (HREC/18/Alfred/102) on 9 July 2018. Study findings will be disseminated in the printed media, and learnt forums.Trial registration number:ACTRN12618000642280.

Project description:ImportanceElectronic health records (EHRs) often include default alerts that can influence physician selection of antibiotics, which in turn may be associated with a suboptimal choice of agents and increased antibiotic resistance.ObjectiveTo examine whether removal of a default alert in the EHR to avoid cephalosporin use in patients with penicillin allergies is associated with changes in cephalosporin dispensing or administration in these patients.Design, setting, and participantsThis retrospective cohort study of a natural experiment included data on patients who had received antibiotic treatment in the hospital or outpatient setting in 2 regions of a large, integrated health system in California from January 1, 2017, to December 31, 2018. Of 4 398 792 patients, 4 206 480 met the eligibility criteria: enrollment in the health system during antibiotic use, availability of complete demographic data, and use of antibiotics outside of the washout period.Interventions or exposuresOral or parenteral antibiotics dispensed or administered after removal of an EHR alert to avoid cephalosporin use in patients with a recorded penicillin allergy.Main outcomes and measuresProbability that an antibiotic course was a cephalosporin. A multinomial logistic regression model was used to examine the change in rates of cephalosporin use before and after an EHR penicillin allergy alert was removed in 1 of the study regions. Temporal changes in use rates were controlled for by comparing changes in cephalosporin use among patients with or without a penicillin allergy at the site that removed the warning and among patients at a comparison site that retained the warning. Regression models were used to examine adverse events.ResultsOf the 4 206 480 patients who met all inclusion criteria, 2 465 849 (58.6%) were women; the mean (SD) age was 40.5 (23.2) years. A total of 10 652 014 antibiotic courses were administered or dispensed, divided approximately evenly between the period before and after removal of the warning. Before removal of an alert in the electronic health record system to avoid prescribing of cephalosporins to patients with a penicillin allergy at 1 of the 2 sites, 58 228 courses of cephalosporins (accounting for 17.9% of all antibiotic use at the site) were used among patients with a penicillin allergy; after removal of the alert, administration or dispensing of cephalosporins increased by 47% compared with cephalosporin administration or dispensing among patients without a penicillin allergy at the same site and patients at the comparison site that retained the warning (ratio of ratios of odds ratios [RROR], 1.47; 95% CI, 1.38-1.56) . No significant differences in anaphylaxis (9 total cases), new allergies (RROR, 1.02; 95% CI, 0.93-1.12), or treatment failures (RROR, 1.02; 95% CI, 0.99-1.05) were found at the course level. No significant differences were found in all-cause mortality (ratio of ratios of rate ratios [RRRR], 1.03; 95% CI, 0.94-1.13), hospital days (RRRR, 1.04; 95% CI, 0.99-1.10), and new infections (Clostridioides difficile: RRRR, 1.02; 95% CI, 0.84-1.22; methicillin-resistant Staphylococcus aureus: RRRR, 0.87; 95% CI, 0.75-1.00; and vancomycin-resistant Enterococcus: RRRR, 0.82; 95% CI, 0.55-1.22) at the patient level.Conclusions and relevanceIn this cohort study, removal of a warning in the electronic health record to avoid cephalosporin use in patients with penicillin allergies was associated with increased administration and dispensing of cephalosporin. This simple and rapidly implementable system-level intervention may be useful for improvement in antibiotic stewardship.

Dataset Information

Increasing cefazolin use for surgical prophylaxis in penicillin-allergy-labeled patients.

Objective

Design

Setting

Patients

Methods

Results

Conclusions

Publications

Increasing cefazolin use for surgical prophylaxis in penicillin-allergy-labeled patients.

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