Holland Alexis M, Lorenz William R, Ricker Ansley B, Mead Brittany S, Scarola Gregory T, Davis Bradley R, Kasten Kevin R, Kercher Kent W, Jaffa Rupal, Davidson Lisa E, Boger Michael S, Augenstein Vedra A, Heniford B Todd
Division of Gastrointestinal and Minimally Invasive Surgery, Department of Surgery, Carolinas Medical Center, Charlotte, NC.
Division of Colorectal Surgery, Department of Surgery, Carolinas Medical Center, Charlotte, NC.
Surgery. 2025 Mar;179:108802. doi: 10.1016/j.surg.2024.08.029. Epub 2024 Sep 20.
Beta-lactam prophylaxis is the first-line preoperative antibiotic in open abdominal wall reconstruction. However, of the 11% patients reporting a penicillin allergy (PA), most receive second-line, non-β-lactam prophylaxis. Previously, abdominal wall reconstruction research from our institution demonstrated increased wound complications, readmissions, and reoperations with non-β-lactam prophylaxis. Therefore, a collaborative quality improvement initiative was developed with the infectious disease service, and a penicillin allergy protocol was instituted that stratified patients' risk of allergic reaction with a goal to increase β-lactam prophylaxis use. The effect of the penicillin allergy protocol on open abdominal wall reconstruction outcomes was prospectively evaluated.
Patients with penicillin allergy undergoing open abdominal wall reconstruction were identified and grouped according to penicillin allergy protocol implementation. Pre-penicillin allergy protocol underwent open abdominal wall reconstruction before January 1, 2020, predominantly receiving non-β-lactam prophylaxis; post-penicillin allergy protocol underwent open abdominal wall reconstruction between January 1, 2020-November 1, 2023, predominantly receiving β-lactam prophylaxis. Incidence of surgical site infection was the primary outcome. Standard and inferential statistical analyses were performed.
Of 315 patients with penicillin allergy, 250 underwent open abdominal wall reconstruction pre-penicillin allergy protocol and 65 post-penicillin allergy protocol. Pre- and post-penicillin allergy protocol were similar in allergic reaction severity history, sex, race, age, diabetes, American Society of Anesthesiologists score, hernia defect size, and mesh type (P > .05). Post-penicillin allergy protocol had lower body mass index (33.4 ± 7.9 vs 29.8 ± 5.3 kg/m; P = .002) and fewer active smokers (12.4% vs 1.5%; P = .019). Expectedly, post-penicillin allergy protocol received more β-lactam prophylaxis (22.8% vs 83.1%; P < .001) and no antibiotic-induced allergic reactions. Post-penicillin allergy protocol had significantly fewer surgical site infections (24.4% vs 3.1%; P < .001), wound breakdown (16.0% vs 3.1%; P = .004), reoperations (19.2% vs 0.0%; P < .001), and readmissions (25.3% vs 9.2%; P = .006) but no statistically significant reduction in recurrence (8.4% vs 1.5%; P = .057).
The penicillin allergy protocol safely increased the number of patients with penicillin allergy undergoing open abdominal wall reconstruction receiving β-lactam prophylaxis and decreased the rate of surgical site infections, wound complications, reoperations, and readmissions. These data supported the systemwide implementation of the penicillin allergy protocol for both general and orthopedic surgery, which has been incorporated into the electronic medical record of 13 hospitals within the system.
β-内酰胺类预防性用药是开放性腹壁重建术前的一线抗生素。然而，在报告有青霉素过敏（PA）的患者中，11%的患者大多接受二线非β-内酰胺类预防性用药。此前，我们机构的腹壁重建研究表明，使用非β-内酰胺类预防性用药会增加伤口并发症、再入院率和再次手术率。因此，我们与传染病科开展了一项合作质量改进计划，并制定了青霉素过敏方案，该方案对患者过敏反应的风险进行分层，目标是增加β-内酰胺类预防性用药的使用。我们前瞻性地评估了青霉素过敏方案对开放性腹壁重建结果的影响。
确定有青霉素过敏且接受开放性腹壁重建的患者，并根据青霉素过敏方案的实施情况进行分组。青霉素过敏方案实施前，于2020年1月1日前接受开放性腹壁重建，主要接受非β-内酰胺类预防性用药；青霉素过敏方案实施后，于2020年1月1日至2023年11月1日期间接受开放性腹壁重建，主要接受β-内酰胺类预防性用药。手术部位感染的发生率是主要结局指标。进行了标准和推断性统计分析。
在315例有青霉素过敏的患者中，250例在青霉素过敏方案实施前接受了开放性腹壁重建，65例在青霉素过敏方案实施后接受了开放性腹壁重建。青霉素过敏方案实施前后，在过敏反应严重程度病史、性别、种族、年龄、糖尿病、美国麻醉医师协会评分、疝缺损大小和补片类型方面相似（P>.05）。青霉素过敏方案实施后患者的体重指数较低（33.4±7.9与29.8±5.3kg/m²；P=.002），且现吸烟者较少（12.4%与1.5%；P=.019）。不出所料，青霉素过敏方案实施后接受β-内酰胺类预防性用药的患者更多（22.8%与83.1%；P<.001），且无抗生素引起的过敏反应。青霉素过敏方案实施后，手术部位感染（24.4%与3.1%；P<.001）、伤口裂开（16.0%与3.1%；P=.004）、再次手术（19.2%与0.0%；P<.001）和再入院（25.3%与9.2%；P=.006）的发生率显著降低，但复发率无统计学显著降低（8.4%与1.5%；P=.057）。
青霉素过敏方案安全地增加了有青霉素过敏且接受开放性腹壁重建的患者接受β-内酰胺类预防性用药的人数，并降低了手术部位感染率、伤口并发症、再次手术率和再入院率。这些数据支持在普通外科和骨科手术中在全系统实施青霉素过敏方案，该方案已纳入该系统内13家医院的电子病历中。
