An interesting article was recently published showing that most people who think they are penicillin allergic actually aren’t. The importance of this extends well beyond plastic surgery, but it is also important for plastic surgeons and their patients.
Antibiotic coverage for most plastic surgery procedures is short term and basic. Many previous studies, including from infectious disease specialists, advocate the use of the simplest regimen that is effective for the type of surgery that is being done. For most procedures, this would be antibiotic coverage with a first generation cephalosporin, such as Cephalexin (brand name Keflex).
The reason for basic antibiotic coverage is to properly treat the perioperative timeframe and to cause the least chance of development of antibiotic resistance, both in that treated patient and also across society. Think about it this way: it is easy to fall into the idea that treating this one patient with a high-end, advanced antibiotic won’t cause a problem with bacterial resistance, but if you multiply that by the number of patients treated worldwide, and knowing that antibiotic resistance develops in a certain percentage of cases, it is easy to understand why we have such a huge problem with antibiotic resistant bacteria, such as MRSA (methicillin resistant staph aureus). An example is breast augmentation. Annually in the U.S., there are over 300,000 breast augmentations performed. If 20% of those patients are receiving high-grade antibiotics rather than first generation antibiotics, then that is 60,000 chances for development of drug resistance.
In an uncomplicated surgery, using a basic antibiotic versus a high-grade antibiotic is just as effective in reducing the chance of an infection. Regardless of antibiotic coverage, infections will occasionally occur.
Now, the importance of this article is this. In the past number of years, there was some thought that if someone was allergic to penicillin, that there was a reasonable chance that they could be allergic to a cephalosporin such as Keflex due to the somewhat similar molecular structure.
In reality, the cross-reactivity for allergies between these two drugs is extremely small. As a matter of fact, many years ago, the mini-bible of antibiotic use, the Sanford Handbook, said that there was an almost zero incidence of cross reactivity.
So why does all this matter? To this day, many physicians and surgeons think that if someone states they have a penicillin allergy that they should avoid a cephalosporin and therefore they use a higher-grade antibiotic. This has been generally proven wrong in many studies. Of course, there are situations when someone can be allergic to both types of antibiotics, but that can only be determined if they have an allergic reaction or undergo allergy testing.
The moral to the story is that using the most basic antibiotic coverage is best in uncomplicated elective surgery, including plastic surgery. Jumping to high-grade, advanced antibiotics only promotes bacterial drug resistance and can worsen the epidemic of drug resistant bacteria that we have now with the significant risks associated with antibiotic resistant bacterial infections.