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

Background Suspected penicillin allergic individuals receive suboptimal non-β- lactamsfor intraoperative prophylaxis which may prolong operations and have negative clinical outcomes. We therefore studied if β- lactamde-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, β- lactamskin 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 β- lactamallergic on skin testing. Of the remaining 190 skin test negative patients, 146 were β- lactamchallenged. Only 5% reacted and were considered β- lactamallergic. Cefazolinbecame the perioperative antibiotic of choice for 77% of patients requiring antibiotic prophylaxis. Only 5 confirmed β- lactamallergic patients received intraoperative vancomycin. Patients avoiding use of vancomycinsaved an average of 22 minutes in operative time. Of the 44 patients not having a β- lactamchallenge, 36 received antibiotics and 18 (50%) of these were prescribed intraoperative cefazolin. Conclusion Using this three step process, almost all of those claiming penicillin allergywere de-labeled. In most patients that were drug challenged, β- lactamantibiotics became the perioperative drug of choice. In cases where oral challenge was not used in the assessment only 50% were given a β- lactam. The reduced use of vancomycinminimized delays in initiation of incision time, thus improving operative efficiency. Ultimately, randomized controlled studies are required to objectively determine the effectiveness of this approach.