Second-Line Antibiotic Agents in Patient-Reported Penicillin or Cephalosporin Allergy Have No Negative Impact on Antibiotic Resistance After Hip and Knee Arthroplasty

Labelling patients as allergic to beta-lactam antibiotics is associated with periprosthetic joint infection up to five years following knee arthroplasty

Aims

Periprosthetic joint infections (PJIs) represent a significant complication of total knee arthroplasty (TKAs). However, the influence of drug or beta-lactam (BL) antibiotic allergy labelling of patients on PJI remains largely unknown. In this study, we examine the association between patients labelled with a BL allergy and the occurrence of PJI among patients undergoing TKA. We also assess the prevalence of incorrect patient labelling and explore the feasibility of a multidisciplinary drug allergy testing initiative to detect mislabelling.

Methods

Longitudinal data from all patients who underwent TKA between January 1993 and December 2021 were analyzed. We investigated the association between different risk factors and PJI, with particular focus on patients labelled as having an antibiotic drug allergy. The outcomes of patients with and without a labelled BL allergy were compared. Additionally, patients labelled as having a BL allergy and who had undergone or were scheduled for TKA were prospectively investigated by formal allergy assessment.

Results

Out of 4,730 TKAs, the overall incidence of PJI was 1.0% (47/4,730). Patients labelled as having a BL allergy had a higher incidence of PJI within the first five years post-TKA compared to those without (3.0% (5/165) vs 0.7% (34/4,565); p = 0.001). The presence of a BL allergy label was identified as an independent risk factor for PJI (hazard ratio 4.86 (95% CI 2.05 to 11.53); p < 0.001). Following negative drug provocation testing, the majority of patients (95% (21/22)) evaluated with BL allergy labels were successfully delabelled.

Conclusion

In this longitudinal study, patients labelled as having a BL allergy were associated with having increased risk of PJI following TKA, particularly within the first five years. Given the high rate of patients being mislabelled, we recommend that patients labelled as having a BL allergy should be prioritized for formal allergy assessment and evaluation. Further studies on the impact of preoperative antibiotic allergy delabelling initiatives should be encouraged.

A rapid literature review of the impact of penicillin allergy on antibiotic resistance

Background

Antimicrobial resistance (AMR) is caused by the use and misuse of antibiotics. AMR is a global health concern, to which penicillin allergy (penA) labels appear to contribute. Patients who have penA labels are treated with non-penicillin antibiotics and receive more antibiotics when compared with patients without penA. Although penA is common, after formal allergy assessments, >90% of people with a penA label are found not to be allergic; therefore, broad-spectrum antibiotics are being misused and overused unnecessarily in these patients. Antimicrobial stewardship policies now advocate assessment to identify and remove incorrect penA labels; however, there is limited evidence on whether rectifying incorrect penA labels results in less AMR. This review aimed to assess the association between AMR and antibiotic allergy labels.

Methods

A comprehensive literature search using EMBASE and MEDLINE databases was conducted. Studies were included if they compared the presence of infection or colonization with an antimicrobial-resistant organism in participants with and without antibiotic allergy.

Results

Thirty-three studies were included, and all the studies were observational in design and included a variety of patient groups. Eighteen studies compared AMR outcomes in participants with and without penA, and the rest investigated the impact of beta-lactam allergy or any antibiotic allergy on AMR outcomes. MRSA was the most investigated pathogen, and 11 of 13 studies showed that penA was associated with MRSA. PenA labels were also associated with vancomycin-resistant enterococci (three of five studies). There was limited evidence on the impact of penA on extended-spectrum beta-lactamase-producing Enterobacterales and resistant Streptococcus pneumoniae.

Conclusion

The presence of penA labels is associated with antibiotic resistance in key pathogens in a wide variety of patient groups.