Cefuroxime is a safe alternative for penicillin allergic patients

13 Jun 2024 Cefuroxime is a safe alternative for penicillin allergic patients

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Posted at 11:29h in Blog, Drug Assessments by

The BC Centre for Disease Control (BCCDC) is collaborating with the UBC Therapeutics Initiative (TI) on a project related to providing prescribing Portraits to dentists on appropriate antibiotic use in dentistry.

Surveillance on dental antibiotic prescribing in BC have shown alarmingly high rates of clindamycin prescribing in comparison to international studies.1 One presumable reason for high rates of clindamycin prescribing is its use as an alternative agent for “penicillin allergic” (PCN-allergic) patients. The best available evidence indicates that clindamycin is not more efficacious yet is more strongly associated with the development of C. difficile colitis than other antibiotics.2

Pharmacists are reminded that beta-lactam allergies, particularly allergies to penicillin, are overreported, with about 10% of individuals reporting an allergy in the US.3 However, most reported penicillin allergy is not associated with clinically significant IgE-mediated reactions after penicillin rechallenge.4

Furthermore, recent studies show the cross-reactivity between penicillins and cephalosporins is less than 1% (and no way near the originally quoted 5% rate).5 Cross-reactivity rate between penicillin and cephalosporins depends on the similarity of side chain structure.6 Cephalexin has a similar side chain and is not safe for PCN-allergic patients. Because cefuroxime’s side chain does not resemble that of amoxicillin or penicillin, it can be used safely.7 Very rare but severe reactions such as Stevens-Johnson syndrome, which includes the peeling of skin and usually requires intensive care, remain contraindications to prescribing any beta-lactam (including all cephalosporins).

The following advice is being given by BCCDC and the TI to dentists:

Do not use clindamycin routinely for prophylaxis or management of dental infections. Cefuroxime is a safe option for most patients who HAVE a true penicillin allergy.

Details for antibiotic selection for prophylaxis and treatment of dental infections

In the few patients for whom Bugs & Drugs suggests prophylaxis, prescribe:

  • A single 2g oral dose of amoxicillin given 30-60 minutes before dental surgery, OR
  • A single 500mg oral dose of cefuroxime, if the patient has penicillin allergy

When you receive a cefuroxime prescription from a dentist for a patient with penicillin allergy, remember that it is a safe option, and may be dispensed. For further information, please see the Bugs & Drugs Guidelines on antibiotic use for dental infections.

References

  1. Thompson W, Teoh L, Hubbard CC, Marra F, Patrick DM, Mamun A, Campbell A, Suda KJ. Patterns of dental antibiotic prescribing in 2017: Australia, England, United States, and British Columbia (Canada). Infect Control Hosp Epidemiol. 2022 Feb;43(2):191-198. DOI: 10.1017/ice.2021.87. Epub 2021 Apr 5. PMID: 33818323; PMCID: PMC9044466.
  2. Brown KA, Khanafer N, Daneman N, Fisman DN. Meta-analysis of antibiotics and the risk of community-associated Clostridium difficile infection. Antimicrob Agents Chemother. 2013 May;57(5):2326-32. DOI: 10.1128/AAC.02176-12. Epub 2013 Mar 11. PMID: 23478961; PMCID: PMC3632900.
  3. Macy E. Penicillin and beta-lactam allergy: epidemiology and diagnosis. Curr Allergy Asthma Rep. 2014 Nov;14(11):476. DOI: 10.1007/s11882-014-0476-y. PMID: 25216741.
  4. Sacco KA, Bates A, Brigham TJ, Imam JS, Burton MC. Clinical outcomes following inpatient penicillin allergy testing: A systematic review and meta-analysis. Allergy. 2017 Sep;72(9):1288-1296. DOI: 10.1111/all.13168. Epub 2017 Apr 26. PMID: 28370003.
  5. Zagursky RJ, Pichichero ME. Cross-reactivity in β-Lactam Allergy. J Allergy Clin Immunol Pract. 2018 Jan-Feb;6(1):72-81.e1. DOI: 10.1016/j.jaip.2017.08.027. PMID: 29017833. Epub 2017 Oct 7. Erratum in: J Allergy Clin Immunol Pract. 2022 Feb;10(2):651. DOI: 10.1016/j.jaip.2021.12.003. PMID: 35144779.
  6. Picard M, Robitaille G, Karam F, Daigle JM, Bédard F, Biron É, Tardif MR, Lacombe-Barrios J, Bégin P. Cross-Reactivity to Cephalosporins and Carbapenems in Penicillin-Allergic Patients: Two Systematic Reviews and Meta-Analyses. J Allergy Clin Immunol Pract. 2019 Nov-Dec;7(8):2722-2738.e5. DOI: 10.1016/j.jaip.2019.05.038. Epub 2019 Jun 4. PMID: 31170539.
  7. Patrick DM, Al Mamun A, Smith N, Rempel E, Calissi P, Blondel-Hill E. BCMJ 2019; 61(9):350–351,361. https://bcmj.org/bccdc/beta-lactam-allergy-benefits-de-labeling-can-be-achieved-safely
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