Title: Incorporating penicillin allergy assessment in preoperative evaluation: landmine antimicrobial stewardship effort in support of surgical services within a military treatment facility
Authors: Kailey B. Moss, PharmD; Memar D. Ayalew, PharmD, BCIDP, AAHIVP
Learning Objective: Describe the impact pharmacist-led penicillin de-labeling services can have on optimizing surgical prophylaxis.
Background/Objective: Identify patients with penicillin and/or other β-lactam allergies ahead of elective surgical procedures, provide a link to appropriate de-labeling services in the perioperative arena, and facilitate access to first-line prophylactic antibiotics.
Methods: Utilizing generated reports, pharmacist-led Penicillin Allergy Management (PAM) clinic personnel screened and identified the target population: patients > 18 years of age, non-pregnant, labeled penicillin (PCN) and/or other β-lactam allergy, and anticipated procedure between Oct. 1st to Dec. 31st, 2025. An Antimicrobial Stewardship Pharmacist then risk-stratified patients with labeled PCN allergies using previously validated risk assessment tools (PEN-FAST and PAT-C score), with low-risk patients contacted to schedule a direct oral amoxicillin challenge (DOAC) appointment prior to respective surgery. Patients identified as having moderate to high risk PCN and/or cephalosporin allergies were referred to the Allergy and Immunology (A/I) clinic for further evaluation by an allergist. Upon successful intervention either by PAM or the A/I clinic, the allergy was removed from the health record, and the patient was longitudinally followed for utilization of first-line prophylactic antibiotics.
Results: A total of 962 patients were screened over the course of the 3-month period with 99 (10%) patients flagged as having aPCN and/or other β-lactam allergy, 93-99% of whom were stratified as having low-risk PCN allergy. Twenty patients in this cohort were de-labeled successfully either by DOAC or chart review: 14 were de-labeled prior and 6 were de-labeled after their respective procedure. Of the 14 patients de-labeled prior to surgery, 10/14 required administration of systemic antibiotics with 8/10 (80%) receiving first-line surgical prophylaxis. This compares to only 15/38 (39%) patients who received first-line surgical prophylaxis in individuals unable to receive intervention prior to procedure (p-value < 0.05).
Conclusion: Consistent with reported literature, we found local prevalence of patients with PCN and/or other β-lactam allergy in this study cohort to be 10%. Following successful pharmacist-driven de-labeling, 80% of patients received first-line prophylactic antibiotics. This demonstrates that appropriate de-labeling in the perioperative arena is essential to optimizing surgical prophylaxis, and by extension, critical to improving overall patient outcomes.
Self-Assessment Question: Which tool(s) can be utilized to determine risk of an IgE-mediated reaction to a direct oral amoxicillin challenge in patients with a penicillin allergy? A. PEN-FAST Score B. PAT-C Score C. q-SOFA Score D. MELD Score E. Both A and B
