What are the alternative prophylactic antibiotics for skin traction in patients with an allergy to antibiotics?

From the Guidelines

For patients with allergies to antibiotics who require skin traction, alternative prophylactic antibiotics include clindamycin and gentamicin, as recommended in the most recent guidelines 1. The choice of alternative antibiotic depends on the nature of the patient's allergy, particularly if they have a beta-lactam allergy. When selecting an alternative, consider the patient's specific allergy history, local bacterial resistance patterns, and individual risk factors. Some key points to consider when choosing an alternative antibiotic include:

• The patient's specific allergy history, including the type of reaction experienced
• Local bacterial resistance patterns
• Individual risk factors, such as the presence of other medical conditions
• The potential for cross-reactivity with other antibiotics In general, clindamycin and gentamicin are effective alternatives for patients with beta-lactam allergies, as they work by different mechanisms than beta-lactams and provide effective coverage against common skin flora while avoiding allergic reactions 1. It's essential to document the specific antibiotic allergy in the patient's chart, including the type of reaction experienced, to guide future antibiotic selections. Prophylaxis should typically be administered 30-60 minutes before the procedure and, depending on the complexity and duration of traction application, may continue for 24 hours post-procedure. Other studies have also recommended the use of alternative antibiotics, such as vancomycin or fluoroquinolones, in certain situations 1. However, the most recent and highest quality study recommends clindamycin and gentamicin as the alternative prophylactic antibiotics of choice for patients with allergies to antibiotics who require skin traction 1.

From the FDA Drug Label

To reduce the development of drug-resistant bacteria and maintain the effectiveness of Clindamycin Injection, USP and other antibacterial drugs, Clindamycin Injection, USP should be used only to treat or prevent infections that are proven or strongly suspected to be caused by susceptible bacteria Vancomycin Hydrochloride for Injection, USP is indicated for the treatment of serious or severe infections caused by susceptible strains of methicillin-resistant (β-lactam-resistant) staphylococci It is indicated for penicillin-allergic patients, for patients who cannot receive or who have failed to respond to other drugs, including the penicillins or cephalosporins, and for infections caused by vancomycin-susceptible organisms that are resistant to other antimicrobial drugs Both animal and human data suggest that AZACTAM (aztreonam for injection, USP) is rarely cross-reactive with other beta-lactam antibiotics and weakly immunogenic.

Alternative Prophylactic Antibiotics for Skin Traction:

• Clindamycin: may be used for skin and skin structure infections caused by Streptococcus pyogenes, Staphylococcus aureus, and anaerobes 2
• Vancomycin: may be used for skin and skin structure infections caused by vancomycin-susceptible organisms, including methicillin-resistant staphylococci 3
• Aztreonam: may be used for patients with a history of hypersensitivity to beta-lactams, but should be administered with caution 4

From the Research

Alternative Prophylactic Antibiotics for Skin Traction

In patients with an allergy to antibiotics, alternative prophylactic antibiotics can be used for skin traction. The following options are available:

• Clindamycin: This antibiotic can be used as an alternative surgical prophylactic antibiotic in patients with penicillin or cephalosporin allergy labels 5.
• Vancomycin: This antibiotic can be used as an alternative prophylactic antibiotic in patients with a penicillin allergy, but it can cause a reaction that ranges from erythema and pruritus to clinically significant hypotension 6, 7.
• Cefazolin: This antibiotic can be safely administered to patients with a penicillin allergy, and no patient with a penicillin allergy and given cefazolin experienced a reaction 6.

Considerations for Antibiotic Administration

When administering antibiotics to patients with an allergy, the following considerations should be taken into account:

• A detailed history of antibiotic allergy is important to determine the risk of an allergic reaction 5, 8, 7.
• Allergy testing and/or direct oral challenge can be used to de-label unsubstantiated penicillin or cephalosporin allergy and ultimately reduce the incidence of surgical site infections (SSIs) 5.
• Patients with a penicillin or cephalosporin allergy were less likely to receive prophylactic antibiotics within the recommended 60 minutes prior to surgical incision, and clear plans and communication are important for ensuring proper antibiotic administration 9.
• The cross-reactivity between penicillins and second- or third-generation cephalosporins is probably no higher than is the cross-reactivity between penicillins and other classes of antibiotics 8.