ACE Question

ASA Monitor 01 2018, Vol.82, 34.

A patient with a history of anaphylaxis to penicillin is most likely to have an increased risk for cross-reactivity to which of the following generations of cephalosporin antibiotics?

• (A) First-generation, such as cefazolin (Ancef, Kefzol)
• (B) Second-generation, such as cefuroxime (Ceftin)
• (C) Third-generation, such as ceftriaxone (Rocephin)
• (D) Fourth-generation, such as cefepime (Maxipime)

Patient self-reporting of drug allergies is often an unreliable predictor of risk for anaphylaxis. Many patients report adverse experiences caused by predictable side effects or idiosyncratic reactions as “allergies.” Any drug given during the perioperative period has the potential to precipitate an immune hyper-sensitivity response. Some medications are capable of inducing histamine release or complement activation in the absence of an antigen-specific antibody, creating the same clinical manifestations as anaphylaxis.

The reported rate of anaphylaxis to antibiotics varies widely, with 1 report quoting an occurrence of 0.004 percent to 0.015 percent for penicillin and 0.0001 percent to 0.1 percent for cephalosporins. Management of the patient with a history of penicillin allergy who is to receive a cephalosporin perioperatively is still not clearly defined by current data.

Historically, a high degree of cross-reactivity has been described between penicillin and first-generation cephalosporin antibiotics. This was based on case reports, the results of skin testing, and in vitro analysis. There has been no significant cross-reactivity demonstrated between penicillin and second- or third-generation cephalosporins.

Both skin testing and in vitro testing (e.g., radioallergosorbent test and the enzyme-linked immunosorbent assay) can produce false-positive results, and patients who have positive antibodies by in vitro testing may not necessarily experience anaphylaxis on exposure to the antigen. In some reports, up to 85 percent of patients who report a history of allergy to penicillin do not have IgE antibodies and therefore may be at a negligible risk for anaphylaxis on exposure to cephalosporin antibiotics. Should it be necessary to administer a cephalosporin to a patient who has either a positive skin test to penicillin or a history of anaphylaxis to penicillin in the absence of skin testing information, it is commonly recommended that the first dose of cephalosporin be given gradually under close observation.

First-generation cephalosporins (e.g., cefazolin) are the most common class of antibiotics to have cross-reactivity with penicillin. Cefuroxime is a second-generation cephalosporin and is less likely to exhibit cross-reactivity to penicillin. Cefotaxime and ceftriaxone are third-generation cephalosporins and are less likely to exhibit cross-reactivity to penicillin.

It should be noted that the Surgical Care Improvement Program (SCIP) criteria are constantly evolving. The 2014 SCIP criteria mandate avoidance of any cephalosporin if the patient reports any form of reaction to penicillin, specifically including a history of gastric distress following administration of penicillin.

Bibliography:

PG, BF, RK, MK, MC, R, eds. Clinical Anesthesia. 7th ed. Philadelphia, PA: Wolters Kluwer/Lippincott Williams & Wilkins; 2013:298-300, 1236.

Levy JH, Adkinson NFJr . Anaphylaxis during cardiac surgery: implications for clinicians. Anesth Analg. 2008;106(2):392–403.

Specifications Manual for Joint Commission National Quality Core Measures (2010B). Surgical Care Improvement Project (SCIP). https://manual.jointcommission.org/releases/archive/TJC2010B1/SurgicalCareImprovementProject.html. Accessed May 23, 2017.

Specifications Manual for Joint Commission National Quality Core Measures (2010B). Antibiotic Allergy. https://manual.jointcommission.org/releases/archiveTJC2010B1/DataElem0013.html. Accessed May 23, 2017.

Answer: A