Dear Surgeons: It is okay to use cefazolin in patients with a penicillin allergy

Even when those patients have a known history of anaphylaxis to penicillin

I am starting a new series with the intent of speaking to our colleagues operating across the drapes. My hope is that these will be helpful, friendly pieces to share with them when the need arises.

Cefazolin is a preferred antibiotic for surgical site infection (SSI) prophylaxis. In many patients with penicillin allergies, anesthesiologists and surgeons alike use alternatives such as clindamycin and vancomycin. Some studies have shown a higher incidence of SSI when using alternatives to cefazolin. However evidence on this is mixed and may be seen only in certain subspecialties. A major downside to using clindamycin is that it increases the risk of Clostridioides difficile infection when compared with cephalosporins. For these reasons, cefazolin is more desirable.

The good news is that there is no need to avoid using cefazolin, even in patients with a known history of anaphylaxis to penicillin. The 2022 drug allergy practice parameters update from the American Academy of Allergy, Asthma, and Immunology states: “Patients with a history of urticaria to a penicillin can receive any cephalosporin routinely without prior testing. In contrast, for those rare patients with a history of anaphylaxis to penicillin, a non–cross-reactive cephalosporin (e.g., cefazolin) can be administered routinely without prior testing.” A recent study in joint replacement surgery showed no increased incidence of anaphylaxis when using cefazolin in patients with a known history of anaphylaxis to penicillin.

Spread the word to your colleagues that it is safe to use cefazolin in patients with a penicillin allergy.