Raising the bar on surgical site infection bundles: Preoperative penicillin allergy testing in gynecologic oncology patients with a reported penicillin allergy - A quality improvement study.

OBJECTIVES

Practice guidelines advise cefazolin for surgical prophylaxis to reduce surgical site infection (SSI) in clean-contaminated procedures but recommend alternative antibiotics for patients with reported penicillin (PCN) allergy despite increased odds of SSI with alternative antibiotics. We aimed to increase use of cefazolin for SSI prophylaxis from 42% in a 3-year period (preintervention) to 80% by 34 months postintervention by implementing preoperative penicillin allergy testing (PAT) in patients with a reported PCN allergy.

STUDY

DESIGN

This was a prospective quality improvement (QI) initiative from 03/2021 to 12/2023. An EMR-embedded best practice advisory (BPA) alert prompted preoperative PAT for patients with reported PCN allergies. Our primary outcome measure was use of cefazolin for SSI prophylaxis at surgery, when indicated. We deployed iterative process modifications based on successive plan-do-study-act (PDSA) cycles using the Model for Improvement. Process and outcome data were analyzed using run charts.

RESULTS

We identified 119 patients who initially reported a penicillin allergy during our study period. The use of cefazolin at the time of surgery significantly increased from 42% (3-year pre-intervention period) to 77.3% (2-year postintervention period), p ≤0.01. Postintervention, the median cefazolin use was 66% of cases by 34 months. 29.4% of patients completed PAT compared to none in the 12 months preceding our intervention. Following the intervention, our SSI rate was 0% (0 of 119) compared to 2.8% pre-intervention (5 of 176).

CONCLUSIONS

Preoperative PAT is a feasible strategy for increasing the best practice use of cefazolin for SSI prophylaxis in those reporting PCN allergy. PAT as routine preoperative care may promote antimicrobial stewardship and decrease SSI risk.