8 - 11 Orthopaedic procedures are at particular risk, given the implanted material that results in both an increased propensity for developing infection and a more difficult process of eradicating infection once it occurs. 8 In addition to causing notable morbidity and mortality, SSIs make up 34% of total healthcare costs related to healthcare-associated infections, with an estimated attributable cost of $20,000 per case. 5 - 7 In another multisite, prospective cohort study, beta-lactam allergic patients who received a non–beta-lactam antibiotic as opposed to a beta-lactam antibiotic had markedly more adverse events reported in the form of hospital readmissions for the same infection, acute kidney injury, C difficile, or other drug-related events (OR 3.2, 95% CI 1.28 to 7.89). 4 The use of these second-line antibiotics leads to increased healthcare-associated infections, including a 23% increased odds of Clostridium difficile, a 14% increased odds of methicillin-resistant Staphylococcus aureus, and a 30% increased odds of vancomycin-resistant Enterococcus. #Penicillin allergy cross reactivity driver3 In orthopaedic surgery, a PAL is the primary driver for choosing an alternative perioperative antibiotic, with clindamycin being used most frequently (Odds Ratio 34.6, 95% Confidence Interval 29.9 to 30.1, P < 0.005). 3 With more than 8,000 penicillin-allergic patients reviewed and more than half of those patients having orthopaedic conditions, the authors found a 50% increased odds of SSI among patients reporting a penicillin allergy entirely attributable to the use of a beta-lactam alternative antibiotic (primarily clindamycin or vancomycin). A compelling article published in November 2019 correlates the risk of having a PAL with developing surgical site infection (SSI). 1, 2 Having a PAL for a patient undergoing surgical intervention is not benign. 1 With this emerging knowledge, the new term coined to refer to a penicillin allergy that has not yet been evaluated is penicillin allergy label (PAL). Penicillin allergies are reported by 8% to 15% of the US population, but up to 95% of these allergies do not correspond to a true allergy when tested.
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