Cefazolin, a first-generation cephalosporin, is the guideline-recommended antibiotic for most surgical procedures (21). Patients reporting a PCN allergy are less likely to receive cefazolin and more likely to receive clindamycin or vancomycin resulting in increased odds of developing a surgical site infection (7,22) or develop adverse effects from both antibiotics.

In addition, the following are disadvantages of using vancomycin or clindamycin preoperatively:

Vancomycin –

• Less effective at preventing Methicillin-Susceptible Staphylococcus aureus (MSSA) infections compared to cefazolin (1)
• Potential nephrotoxicity
• Blumenthal (7) reported that among 95% of patients receiving vancomycin, vancomycin was not administered within the recommended time frame of 60-120 minutes before incision.

Clindamycin –

• 3-fold increased risk of Clostridioides difficile infection (CDI) compared to other antibiotics
• Clindamycin resistance to Staphylococcus aureus ( both MSSA and MRSA) is increasing.

It is now known that the R1 group side chain is the predominant allergenic determinant in patients with a beta-lactam allergy and that patients with a confirmed IgE-mediated beta-lactam allergy can safely receive other beta-lactams that do not share similar R1 side chain structures (23,24). Cefazolin in particular has a distinct R1 structure that is not shared with other beta-lactams and is thought to be safe to administer even in patients with a history of anaphylaxis to other beta-lactams (23,24). Multiple studies have successfully increased rates of cefazolin use for perioperative prophylaxis in patients with beta-lactam allergy (25,26).

Prior interventions aimed at improving perioperative cefazolin have included:

• a standardized allergy history
• allergy skin testing
• direct drug provocation

However, these interventions have required significant personnel and resource requirements with limited potential for sustainability and scalability.

A recent study showed that implementation of a perioperative allergy and antibiotic assessment tool in patients with reported beta-lactam allergy resulted in a pronounced and sustained increase in perioperative cefazolin use. The tool – Allergy Clarification for Cefazolin Evidence-based Prescribing Tool (ACCEPT) was used by anaesthesiologists and pharmacists in preoperative clinics and operating rooms to quickly identify patients who could safely receive cefazolin (25). During the baseline period, approximately 40% of patients with reported beta-lactam allergy received cefazolin as perioperative prophylaxis. With implementation of ACCEPT, this proportion increased and remained above 80% throughout the intervention period – 18 months.

The ACCEPT protocol is described in the tool kit section.