De-labeling of β-lactam allergy reduces intraoperative time and optimizes choice in antibiotic prophylaxis

Background: Suspected penicillin allergic individuals receive suboptimal non-beta-lactams for intraoperative prophylaxis which may prolong operations and have negative clinical outcomes. We therefore studied if beta-lactam de-labeling optimized choice of prophylactic antibiotics and improved intraoperative time efficiency. Methods: A multistep approach was used. It included a risk assessment tool by an allergist, beta-lactam skin testing and oral provocation. To determine the value of de-labeling, we appraised intraoperative antibiotic choices and correlated them with time to first incision. Results: A total of 194 patients were evaluated preoperatively. Four patients were diagnosed beta-lactarn allergic on skin testing. Of the remaining 190 skin test negative patients, 146 were beta-lactam challenged. Only 5% reacted and were considered beta-lactam allergic. Cefazolin became the perioperative antibiotic of choice for 77% of patients requiring antibiotic prophylaxis. Only 5 confirmed beta-lactam allergic patients received intraoperative vancomycin. Patients avoiding use of vancomycin saved an average of 22 minutes in operative time. Of the 44 patients not having a beta-lactam challenge, 36 received antibiotics and 18 (50%) of these were prescribed intraoperative cefazolin. Conclusion: Using this three step process, almost all of those claiming penicillin allergy were de-labeled. In most patients that were drug challenged, beta-lactam antibiotics became the perioperative drug of choice. In cases where oral challenge was not used in the assessment only 50% were given a beta-lactam. The reduced use of vancomycin minimized delays in initiation of incision time, thus improving operative efficiency. Ultimately, randomized controlled studies are required to objectively determine the effectiveness of this approach. (C) 2018 Published by Elsevier Inc.