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Outcomes of Administering Cefazolin vs. Other Antibiotics in Penicillin-Allergic Patients for Surgical Prophylaxis at a Major Canadian Teaching Hospital

Tim T.Y. Lau and Nilu Partovi
Vancouver General Hospital, Vancouver, British Columbia

Background:  Cefazolin surgical prophylaxis is associated with better patient outcomes, however, its use in penicillin-allergic patients is controversial. We evaluated safety and efficacy of cefazolin as surgical prophylaxis in penicillin-allergic patients, including those with anaphylaxis histories.

Patients and Methods: We conducted a pre- and post-intervention quality improvement evaluation of an institution-wide policy change at a tertiary-care hospital, before (October 2017 to January 2018), during (February 2018 to September 2018), and after (October 2018 to October 2019) transition to routine cefazolin prophylaxis for penicillin-allergic patients, including those with anaphylaxis histories but excluding severe delayed reactions (e.g. Stevens-Johnson syndrome).

Retrospective data was collected on all surgical prophylaxis patients with penicillin-anaphylactic histories between October 2017 to September 2018.  From October 2018, we prospectively reviewed adverse events with cefazolin. Primary outcome was adverse events in penicillin-allergic patients receiving cefazolin peri-operatively.

Results: From October 2017 to October 2019, 27,467 surgeries were performed. Of 220 patients with penicillin-anaphylactic histories reviewed prior to full-policy change, no statistically significant differences were reported in allergic reactions (P=0.70), surgical site infections (P=1.00), or adverse events (P=0.32) with cefazolin compared to other antibiotics. Post-policy implementation, cefazolin usage increased 18.2%, while vancomycin and clindamycin decreased by 11.4% and 62.0%, respectively. No anaphylaxis was documented in penicillin-allergic patients receiving cefazolin in either the review or quality assurance follow-up after the change. Of 3 patients developing reactions to cefazolin, none had histories of penicillin allergy. Surgical site infection rates were similar between pre- and post-policy time-periods (P=0.842).

Conclusions: Administration of cefazolin in penicillin-anaphylactic patients for surgical prophylaxis appears to be safe and effective.

Addressing Medication Appropriateness and Polypharmacy in Frail Older Adults in Primary Care

Cheryl A Sadowski 

Misericordia Hospital Geriatric Outpatient Clinic and Edmonton Oliver Primary Care Network, Edmonton

Background: Older adults have the greatest complexity for care and are at risk for polypharmacy and medication safety concerns. Most medications for seniors are started in primary care, yet there are few pharmacists providing care in this setting. 

Objectives: The purpose of our research was to develop an interprofessional seniors-focused clinical service within a Primary Care Network (PCN) in Edmonton, Alberta. The objectives were to determine if a pharmacist-led team assessment could result in reduced medication burden, reduced potentially inappropriate medications (PIM), and improved medication safety. 

Methods: The Geriatric Outpatient Clinic (GOC) team from the Misericordia Community Hospital worked with the Edmonton Oliver PCN to develop process of care pathways for referral, assessment, and documentation. Pharmacists with interest in geriatrics through the PCN completed training at the GOC. Patients in the PCN were identified based on the Edmonton Frail Scale for referral to the Seniors' Hub and underwent a geriatric assessment. 

Results : The initial analysis included 54 patients (61% female, mean age 82 years), with a mean of 5 chronic conditions, enrolled over a 1 year period. Hyperpolypharmacy (10 or more medications) was identified in 67% of patients. The reasons for assessment were falls/mobility (33%), cognition (30%), and polypharmacy/medication review (15%). The pharmacists identified that 61% of patients had untreated conditions, 57% had PIM, and 41% had unnecessary medications. The total number of medications showed a non-significant decline, from 12.1 to 11.7, but the number of PIMs decreased from 1.15 to 0.9 (p=0.006). 

Conclusions: The PCN staff rarely found medications as a reason for referral, yet the majority of frail seniors have medication related problems. The implementation of a pharmacist-led assessment for frail community dwelling seniors reduced the number of PIMs and addressed medication undertreatment. 

Development of Standardized Opioid Prescriptions for Post-Laparoscopic Appendectomy and Cholecystectomy Surgeries and Implementation of Patient Information on Safer Opioid Use

Jenny C Chiu and Alice Watt
North York General Hospital,  Toronto, ON



Background: Opioid prescriptions with duration exceeding 7 days for acute pain were associated with double the likelihood of continued use 1 year later. Quantities prescribed vary widely between prescribers. Excess unused opioids are rarely disposed of properly. A 2017 Ontario Student Drug Use Survey showed that 11% of high school students reported non-medical use of opioids and 55% of the time they were obtained from home.

Objectives: The objectives were to standardize discharge opioid prescriptions focusing on laparoscopic appendectomy and cholecystectomy (LA & LC) surgeries and to develop a patient education sheet on opioids.

Methods: A baseline survey was conducted over 3 months in LA/LC patients to establish their opioid usage, pain control, and whether opioid education was received post-operatively. This data was used to develop a standardized prescription. A patient information sheet on proper opioid use, storage and disposal was developed in collaboration with ISMP Canada and support from the Canadian Patient Safety Institute. A post-implementation survey was completed to assess if patients had adequate supply of pain medications and pain control with the new standardized prescription, and to measure rates of opioid education.

Results: Pre-implementation, surgeons prescribed 20 to 30 opioid pills per prescription. The standardized prescription issued 10 tablets. This led to a 56% decrease in the number of opioids prescribed over the 3-months (from 2672 to 1182 tablets). Results showed that patients were satisfied with their pain control. Patient education on opioids increased from 8.6% to 44%

Conclusions: Implementing a standardized opioid prescription led to a decrease of 1490 opioid tablets prescribed over 3 months. This would amount to around 11,000 less opioid tablets prescribed over 1 year at 1 institution. The opportunity for other surgical programs and institutions to adopt this prescription would mean several thousand less opioids tablets available for diversion. Increasing patient education may potentially decrease opioid-related misuse.