ANTIMICROBIAL PROPHYLAXIS FOR SURGERY IN PATIENTS WITH PENICILLIN ALLERGY Dirk VOGELAERS

1. ANTIMICROBIAL PROPHYLAXIS FOR SURGERY IN PATIENTS WITH PENICILLIN ALLERGY Dirk VOGELAERS Department of General Internal Medicine University Hospital, Gent, Belgium BAPCOC Workshop, January 16th 2014

3. Alert system for penicillin allergy

4. Alert system for penicillin allergy • Systematic central recording of ± penicillin allergy in EPD • Systematic screening through history taking • Process issue (preoperative screening) • Pop up alert in electronic prescription process • Obligatory information in eID

6. Bronchospasms, angio-edema, hypotension, urticaria and pruritic rash are indicative for real IgE mediated penicillin allergy (type I reactions). Only these type I reactions are likely to become more severe over time and to result in anaphylaxis with repeated courses of penicillins.Anaphylactic reactions occur immediately (< 1 hour after exposure), urticaria and angio-edema can present from 1 hour to up to 72 hours after exposure. These reactions can be induced by both the core and the side chain structures of the penicillin. Sanford Guide to Antimicrobial Therapy, BeLux Edition 2012-2013

8. Late reactions (type IV reactions) occurring days or weeks after the initiation of therapy with a penicillin are the most frequent: idiosyncratic skin reactions, late (≥ 3 days after initiation of penicillin the-rapy) macular exanthema, ….These are the most frequent reasons of misdiagnosis of IgE mediated penicillin allergy. Sanford Guide to Antimicrobial Therapy, BeLux Edition 2012-2013

9. Allergic reactions occur in 0.7 to 8% of patients treated with a penicillin. • Anaphylactic shock occurs in 0.01% of patients treated with a penicilin. Peetermans WE et al, Ned Tijdschr Geneeskd 1999;143:336

12. Campagna JD, J Emerg Med 2012;42:612

13. No side chain similarity between penicillin G on the one hand and • cefazolin or cefuroxime on the other hand. • No side chain similarity between amoxicillin(-clavulanate)/ampicillin • on the one hand and cefazolin or cefuroxime on the other hand. Pichichero ME, Pediatrics 2005;115:1048

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16. Peetermans WE et al, Ned Tijdschr Geneeskd 1999;143:336

17. SWITCH FROM ................ TO .............. • Cefazolin →→ → Vancomycin + Aztreonam • Cefuroxime → → → Vancomycin + Aztreonam • Cefuroxime + → → → Vancomyicin + Aztreonam Anti-anaerobe + Anti-Anaerobe • Amoxicillin-Clavulanate → Vancomycin + Aztreonam + Anti-Anaerobe • (Flucl)oxacillin → → → Vancomycin + Aztreonam • Clindamycin, ciprofloxacin, levofloxacin: not applicable

18. Vancomycin. • 15 mg/kg/dose in children. • 15 mg/kg/dose in (non) pregnant adolescents and adults. • 1 extra dose every 12 hours. • Aztreonam. • 30 mg/kg (not to exceed 2 gm) in children. • 2 gm in (non) pregnant adolescents and adults. • 1 extra dose every 12 hours. • Metronidazole – Ornidazole • 15 mg/kg (not to exceed 500 mg) in children. • 500 mg in (non) pregnant adolescents and adults. • 1 extra dose every 12 hours.

19. Special circumstances: • Neonates: IgE mediated allergy exists? • Renal impairment: no impact, no dose adjustment (applies to aztreonam, metronidazole, ornidazole, vancomycin). • Hepatic impairment. • Aztreonam: no dose adjustment. • Metronidazole, ornidazole: caution, especially in patients with Child Pugh score C. • Vancomycin: no dose adjustment. • (Morbid) obesity. • Vancomycin: based on actual body weight. • Aztreonam, metronidazole, ornidazole: no data available.

20. If cephalosporins are contra-indicated, CDC guidelines recommend either vancomycin or clindamycin. • Belgian Sanfordgroup prefers vancomycin, because: • the number of patients is very limited (if indication is OK), thus limiting the extra cost vs clindamycin. • resistance rates for staphylococci are much lower than for clindamycin [clindamycin-R in 2011 (reference lab data): 6% of MSSA, 40% of MRSA and 18% of CA-MRSA). • clindamycin administration is associated with development of Clostridium difficile associated diarrhea.

24. Karjalainen J et al J Allergy Clin immunol 2005;116:225

25. Case 1. • A 71-year old patient with a history of penicillin allergy is admitted to the hospital for biliary surgery. Hospital protocols foresee cefazolin prophylaxis in this patient. • When the patient was 18 years old, he experienced an ADR to penicillin, which he believes was a rash that lasted a few days. • Since then he has avoided all betalactam antibiotics. What would be your next step? • Administer cefazolin. • Avoid cephalosporins. • Perform skin test and if negative, administer cefazolin. • Desensitize. • Avoid all betalactam antibiotics.

26. Case 2. • A 62-year old patient with a history of penicillin allergy is admitted to the hospital for a hernia repair. • When the patient was 18 years old, he experienced an ADR to penicillin, which he believes was a rash that lasted a few days. • Since then he has avoided all betalactam antibiotics. What would be your next step?

27. Case 3. • A 21-year old patient with a history of penicillin allergy is admitted to the hospital for cardiac implantable electronic device (CIED) implantation. Hospital protocols foresee cefazolin prophylaxis in this patient. • When the patient was 5 years old, he received an oral penicillin and developed ulcers and blistering in his mouth and on his genitals. The antibiotic was discontinued and the patient recovered. • Since then, no further betalactam exposures have been attempted. What would be your next step? • Administer cefazolin. • Desensitize to penicillin and cephalosporins. • Give a test dose of cefazolin and if the patient has no ADR in your office, give the full dose in the operation room. • Switch to vancomcyin + aztreonam. • Perform a penicillin skin test.

28. Thank you for your attention!