De-labeling of ß-lactam allergy reduces intraoperative time and optimizes choice in antibiotic prophylaxis.

BACKGROUND: Suspected penicillin allergic individuals receive suboptimal non-ß-lactams for intraoperative prophylaxis which may prolong operations and have negative clinical outcomes. We therefore studied if ß-lactam de-labeling optimized choice of prophylactic antibiotics and improved intraoperative time efficiency. METHODS: A multistep approach was used. It included a risk assessment tool by an allergist, ß-lactam skin testing and oral provocation. To determine the value of de-labeling, we appraised intraoperative antibiotic choices and correlated them with time to first incision. RESULTS: A total of 194 patients were evaluated preoperatively. Four patients were diagnosed ß-lactam allergic on skin testing. Of the remaining 190 skin test negative patients, 146 were ß-lactam challenged. Only 5% reacted and were considered ß-lactam allergic. Cefazolin became the perioperative antibiotic of choice for 77% of patients requiring antibiotic prophylaxis. Only 5 confirmed ß-lactam allergic patients received intraoperative vancomycin. Patients avoiding use of vancomycin saved an average of 22 minutes in operative time. Of the 44 patients not having a ß-lactam challenge, 36 received antibiotics and 18 (50%) of these were prescribed intraoperative cefazolin. CONCLUSION: Using this three step process, almost all of those claiming penicillin allergy were de-labeled. In most patients that were drug challenged, ß-lactam antibiotics became the perioperative drug of choice. In cases where oral challenge was not used in the assessment only 50% were given a ß-lactam. The reduced use of vancomycin minimized delays in initiation of incision time, thus improving operative efficiency. Ultimately, randomized controlled studies are required to objectively determine the effectiveness of this approach.

Adult primary immune deficiency: what are we missing?

BACKGROUND: More than 200 primary immune deficiencies have been described. In adults, their identification can be difficult. The lack of timely referrals, diagnostic facilities, and available expertise often delay appropriate treatment. Because an increasing number of adults are now diagnosed with immune deficiencies, there is a need to better understand the immune deficits in this age group. The study objective was to analyze the diagnostic spectrum of adults with primary immune deficiency and to determine the presumptive diagnostic accuracy of the referring physicians. METHODS: We conducted a retrospective chart review over a 10-year period of all individuals referred to a dedicated center for adults with primary immune deficiency. Suspected cases were confirmed using standard clinical criteria and state of the art immune assays. RESULTS: Of the 381 individuals studied, 244 were diagnosed as immune deficient. Of these, 210 had primary immune deficiency classified as novel, defined, and undefined. Forty-three patients had a prior diagnosis and were referred for follow-up care, and 201 patients were newly diagnosed. Most patients had common variable immune deficiency. Despite an apparent high index of suspicion in initiating the referrals, only one third of these patients had a prior quantitative assessment of serum immunoglobulins. CONCLUSIONS: In this first known analysis of a large cohort of adults with suspected immune deficiency using established diagnostic criteria, we confirmed the diagnosis in two thirds of all patients. Our findings highlight the wide spectrum of primary immune deficiency states seen in adult medical practices and the need for increased awareness of their existence.