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Misconceptions Surrounding Penicillin Allergy: Implications for Anesthesiologists

Vorobeichik, Leon, MD*; Weber, Elizabeth A., MD, FRCPC†,‡; Tarshis, Jordan, MD, FRCPC*,§

doi: 10.1213/ANE.0000000000003419
Anesthetic Clinical Pharmacology: Special Article

Administration of preoperative antimicrobial prophylaxis, often with a cephalosporin, is the mainstay of surgical site infection prevention guidelines. Unfortunately, due to prevalent misconceptions, patients labeled as having a penicillin allergy often receive alternate and less-effective antibiotics, placing them at risk of a variety of adverse effects including increased morbidity and higher risk of surgical site infection. The perioperative physician should ascertain the nature of previous reactions to aid in determining the probability of the prevalence of a true allergy. Penicillin allergy testing may be performed but may not be feasible in the perioperative setting. Current evidence on the structural determinants of penicillin and cephalosporin allergies refutes the misconception of cross-reactivity between penicillins and cefazolin, and there is no clear evidence of an increased risk of anaphylaxis in cefazolin-naive, penicillin-allergic patients. A clinical practice algorithm for the perioperative evaluation and management of patients reporting a history of penicillin allergy is presented, concluding that cephalosporins can be safely administered to a majority of such patients.

From the *Department of Anesthesia

Division of Clinical Immunology and Allergy, Department of Medicine, University of Toronto, Toronto, Ontario, Canada

Drug Safety Clinic

§Department of Anesthesia, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada.

Published ahead of print May 10, 2018.

Accepted for publication March 30, 2018.

Funding: None.

The authors declare no conflicts of interest.

Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal’s website.

Reprints will not be available from the authors.

Address correspondence to Leon Vorobeichik, MD, Department of Anesthesia, Sunnybrook Health Sciences Centre, University of Toronto, 2075 Bayview Ave, Room M3-200, Toronto, ON M4N 3M5, Canada. Address e-mail to

© 2018 International Anesthesia Research Society
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