Cephalosporin use and patient outcomes following removal of penicillin–cephalosporin cross-reactivity alerts from the electronic health record

Studies have shown there is minimal risk of cephalosporin cross-reactivity with penicillin (PCN), though avoidance in practice still occurs. Avoidance of cephalosporins due to reported PCN allergies can result in negative clinical outcomes. Removal of cross-reactivity alerts from the electronic health record (EHR) may increase cephalosporin utilization. The objective of this study was to evaluate cephalosporin utilization in those with documented intermediate-, high-, and severe-risk allergies following an EHR cross-reactivity alert removal. This was a retrospective, observational, pre–post review of patients with a documented intermediate-, high-, or severe-risk PCN allergy who received at least one dose of a systemic antibiotic for an indication in which a cephalosporin was first line. An EHR alert removal was implemented along with system-wide guideline updates and education. The primary outcome was the rate of cephalosporin utilization. Secondary outcomes included rates of PCN utilization, antibiotic adverse effects, and a composite of treatment failure. A total of 235 patients were included (pre = 118, post = 117). Intermediate-risk allergies made up a majority of the population (74%), with surgical site infection prophylaxis being the most common antibiotic indication (63%). Cephalosporin utilization significantly increased after alert removal (27% vs 67%, P < 0.001). Use of cefazolin increased by 47% ( P < 0.001), while use of alternative agents, clindamycin and vancomycin, decreased by 12.5% ( P = 0.032) and 13.4% ( P = 0.021), respectively. No patients had an allergic reaction to cephalosporins. Removal of a PCN–cephalosporin cross-reactivity alert from the EHR increased cephalosporin utilization without adverse allergy-related sequelae in those with intermediate- and high-risk PCN allergies.