Antibiotic Management of Penicillin Allergies in Plastic Surgery: Current Practices and Attitudes Toward Penicillin Allergy Testing

Goals/Purpose: Over 95% of the approximately 32 million Americans with reported penicillin allergies may be penicillin tolerant upon confirmatory allergy testing.^1,2 However, most of these individuals will not undergo testing and commonly receive b-lactam alternative antibiotics, which are associated with increased risks of C. difficile colitis and antimicrobial resistance as well as decreased efficacy when used for surgical prophylaxis. The purpose of this study was to assess plastic surgeons’ current practices for perioperative antibiotic management of patients labeled as penicillin allergic and their attitudes toward confirmatory allergy testing.

Methods/Technique: A survey study of plastic surgeons practicing in New York City between February and March of 2020 was performed. The survey instrument was designed and pretested to optimize content validity, face validity, and utility, and administered online using Qualtrics software. Surgeons were queried about their perioperative antibiotic management of patients with reported non-anaphylactic penicillin allergies. All responses were anonymous.

Results/Complications: The survey response rate was 38%. Sixty-two percent of plastic surgeon respondents were male and 57% were in practice for more than 20 years. Fifty-two percent were in private practice and 48% in hospital-based practice. For antibiotic prophylaxis of “clean” (CDC Class I) surgical procedures among patients with reported non-anaphylactic penicillin allergies, 38% of respondents said they prescribe a first-generation cephalosporin and 62% prescribe one of the b-lactam alternatives: clindamycin (52%), vancomycin (5%), or ciprofloxacin (5%). For procedures involving placement of either closed-suction drains or permanent implants, the majority of respondents prescribe antibiotics for greater than 24 hours and 33% of respondents prescribe them for greater than 5 days. Lastly, 67% of respondents said they “never” recommend confirmatory penicillin allergy testing, but most were “more likely” to recommend it after being presented with supporting literature.

Conclusion: For patients with reported non-anaphylactic penicillin allergies, the majority of plastic surgeons prescribe perioperative β-lactam alternative antibiotics. Given that β-lactam alternatives are associated with increased complications and decreased efficacy compared to first-generation cephalosporins, and over 95% of patients labeled penicillin allergic may be tolerant, we would encourage all surgeons to consider recommending confirmatory allergy testing routinely in their clinical practices.

References:

1. Shenoy ES, Macy E, Rowe T, Blumenthal KG. Evaluation and Management of Penicillin Allergy: A Review. JAMA. 2019 Jan 15;321(2):188-199. PubMed PMID: 30644987.
2. Castells M, Khan DA, Phillips EJ. Penicillin Allergy. N Engl J Med. 2019 Dec 12;381(24):2338-2351. Review. PubMed PMID: 31826341.