USA: Clinical Opinion on Cefazolin Use

A recent clinical opinion published in the American Journal of Obstetrics and Gynecology supports cefazolin use as a primary antibiotic for prophylaxis in obstetric and gynecological patients with a history of penicillin allergy, even among those who have experienced anaphylactic reactions. This recommendation marks a significant step in ensuring effective antimicrobial care while addressing patient safety concerns.

"The sole exceptions are patients with a history of severe, life-threatening delayed hypersensitivity reactions, including Stevens-Johnson Syndrome. It is essential to incorporate more referrals for penicillin allergy testing into routine obstetric care and preoperative evaluations," Karley J. Dutra, Department of Obstetrics and Gynecology, Medical University of South Carolina, Charleston, SC, and colleagues wrote.

Cefazolin is the primary antibiotic used for prophylaxis in obstetrics and gynecology. However, many patients with a penicillin allergy are prescribed alternative antibiotics due to concerns about potential cross-reactivity with cefazolin. These alternatives can lead to negative outcomes, such as:

• Increased risk of surgical site infections
• Development of antibiotic resistance
• Higher healthcare costs
• Potential for Clostridium difficile infections

The authors highlight that this situation has significant negative consequences for the patients under our care. They advocate for ongoing education among obstetrician-gynecologists and the delabeling of penicillin allergies to optimize antimicrobial prophylaxis.

According to the study authors, the differences in R1 side chains between penicillin and cefazolin suggest that cefazolin is safe for use in patients with penicillin allergy, including those who have experienced IgE-mediated reactions such as anaphylaxis. They emphasize that cefazolin should be avoided only in individuals with a history of severe, life-threatening delayed hypersensitivity reactions, which may manifest as severe cutaneous adverse reactions like Stevens-Johnson Syndrome, as well as hepatitis, nephritis, serum sickness, and hemolytic anemia in response to penicillin.

Furthermore, the authors point out that more than 90% of individuals with a documented penicillin allergy do not have true allergies as confirmed by skin testing. To address this, they recommend increasing referrals for penicillin allergy testing as part of routine obstetric care and preoperative assessments to improve antibiotic prophylaxis practices. The study authors also stress the need for greater education among healthcare providers regarding penicillin allergy assessments and the potential cross-reactivity between penicillins and cephalosporins, aiming to optimize antibiotic prophylaxis in obstetrics and gynecology.

This prompted the authors to conclude that cefazolin is suitable for antimicrobial prophylaxis in most patients with a penicillin allergy, even those who have experienced an anaphylactic reaction to penicillin. The only exceptions are individuals with a history of severe, life-threatening delayed hypersensitivity reactions, including Stevens-Johnson Syndrome.

"Increased referral for penicillin allergy testing should be incorporated into our routine obstetric care and preoperative assessment," they wrote.

Reference

Dutra, K. J., Lazenby, G. B., Goje, O., & Soper, D. E. (2024). Cefazolin as the mainstay for antibiotic prophylaxis in patients with a penicillin allergy in obstetrics and gynecology. American Journal of Obstetrics and Gynecology, 231(4), 430-436. https://doi.org/10.1016/j.ajog.2024.03.019