2025 Southeastern Residency Conference

Title: Evaluation of Clindamycin Use for Surgical Prophylaxis in Patients with Reported Beta-Lactam Allergy
Authors: Jessica Vail, Doug Carroll, Stephen Eure
Background/Purpose: New practice parameters were published in 2022 by the American Academy of Allergy, Asthma, and Immunology (AAAAI) and the American College of Asthma, Allergy, and Immunology (ACAAI), outlining specific recommendations for cephalosporin use in the presence of beta-lactam allergy. For all types of reactions to penicillin (including anaphylaxis), the practice parameters recommend the administration of cefazolin without prior testing precautions (such as penicillin skin testing or oral dose challenges). For all types of cephalosporin reactions, the practice parameters recommend skin testing or an oral dose challenge prior to cefazolin administration. At DCH Health System, clindamycin is commonly used for surgical prophylaxis in the presence of beta-lactam allergy, despite its adverse effect profile (including C. difficile infections) and increased resistance rates with common pathogens found in surgical site infections (such as S. pyogenes and S. agalactiae). The purpose of this review is to characterize current practices at DCH Health System in the context of surgical prophylaxis compared to the 2022 practice parameter update recommendations and identify areas of future improvement.
Methodology: A retrospective chart review was conducted among patients ≥19 years old with labeled penicillin or cephalosporin allergy who received clindamycin monotherapy for surgical prophylaxis from April to June 2024. A total of 100 patients were included in the study. The primary outcome was to determine the number of beta-lactam allergic patients in the sample who would have been candidates for receipt of cefazolin based on the AAAAI/ACAAI practice parameter update. Secondary outcomes evaluated include the characterization of allergy documentation, history of successful cephalosporin administration, incidence of surgical site infections, rehospitalization rates, and incidence C. difficile infections.  
Results: For the primary outcome, 79/100 patients would have been candidates to receive cefazolin without prior precautions. The 21/100 patients reporting a cephalosporin allergy would need either a negative penicillin skin test or an oral dose challenge prior to receiving cefazolin. For secondary outcomes, 33% of patients were candidates for cefazolin administration based on a history of successful cephalosporin administration an allergy comment stating tolerance to cephalosporins. Four percent of patients had a documented surgical site infection at follow-up within 30 days and two of these patients were rehospitalized within the same time-frame. No patient had a documented C. difficile infection within 30 days of clindamycin administration.
Conclusions: Based on the 2022 AAAAI/ACAAI practice parameter update, clindamycin is over-utilized in patients with beta-lactam allergy and its use for surgical prophylaxis is a potential antimicrobial stewardship opportunity for pharmacists.