The Impact of a Reported Penicillin Allergy on Surgical Site Infection Risk

Abstract

Background: A reported penicillin allergy may compromise receipt of recommended antibiotic prophylaxis intended to prevent surgical site infections (SSIs). Most patients with a reported penicillin allergy are not allergic. We determined the impact of a reported penicillin allergy on the development of SSIs.

Methods: In this retrospective cohort study of Massachusetts General Hospital hip arthroplasty, knee arthroplasty, hysterectomy, colon surgery, and coronary artery bypass grafting patients from 2010 to 2014, we compared patients with and without a reported penicillin allergy. The primary outcome was an SSI, as defined by the Centers for Disease Control and Prevention's National Healthcare Safety Network. The secondary outcome was perioperative antibiotic use.

Results: Of 8385 patients who underwent 9004 procedures, 922 (11%) reported a penicillin allergy, and 241 (2.7%) had an SSI. In multivariable logistic regression, patients reporting a penicillin allergy had increased odds (adjusted odds ratio, 1.51; 95% confidence interval, 1.02-2.22) of SSI. Penicillin allergy reporters were administered less cefazolin (12% vs 92%; P < .001) and more clindamycin (49% vs 3%; P < .001), vancomycin (35% vs 3%; P < .001), and gentamicin (24% vs 3%; P < .001) compared with those without a reported penicillin allergy. The increased SSI risk was entirely mediated by the patients' receipt of an alternative perioperative antibiotic; between 112 and 124 patients with reported penicillin allergy would need allergy evaluation to prevent 1 SSI.

Conclusions: Patients with a reported penicillin allergy had a 50% increased odds of SSI, attributable to the receipt of second-line perioperative antibiotics. Clarification of penicillin allergies as part of routine preoperative care may decrease SSI risk.

Keywords: allergy; antibiotic; healthcare-associated infections; prophylaxis; surgical site infections.

Figure 1.

Retrospective cohort of 8385 patients undergoing 9004 surgical procedures from 2010 through 2014 at the Massachusetts General Hospital. Abbreviations: CABG, coronary artery bypass grafting; COLO, colon surgery; HPRO, hip arthroplasty; HYST, hysterectomy; KPRO, knee arthroplasty.

Figure 2.

Perioperative antibiotic use among patients with and without a reported penicillin allergy. *Includes ceftriaxone (n = 4), ertapenem (n = 1), and piperacillin/tazobactam (n = 1) (reported penicillin allergy) and amoxicillin (n = 1), ceftazidime (n = 2), ceftriaxone (n = 20), nafcillin (n = 3), penicillin G (n = 3), piperacillin/tazobactam (n = 9), ertapenem (n = 4), imipenem (n = 4), and meropenem (n = 1) (no reported penicillin allergy). ^†Includes linezolid (n = 4) and other antibiotics (n = 4) (reported penicillin allergy), and azithromycin (n = 2), aztreonam (n = 1), daptomycin (n = 6), linezolid (n = 2), and other antibiotics (n = 3) (no reported penicillin allergy).