From the Guidelines
For a post-operative orthopedic patient requiring surgical prophylaxis who is allergic to Keflex (cephalexin), I recommend vancomycin 30 mg/kg IV over 120 minutes as the first dose, which should be completed 30 minutes before the start of surgery, as this provides effective coverage against common orthopedic surgical site pathogens, including methicillin-resistant Staphylococcus aureus (MRSA) 1. This recommendation is based on the most recent and highest quality evidence available, which prioritizes the use of vancomycin in patients with allergies to beta-lactams, including cephalosporins like Keflex. The dosing and administration guidelines are crucial to ensure adequate tissue concentrations during the surgical procedure.
- Key considerations include:
- Verifying the nature and severity of the patient's Keflex allergy to determine the best alternative
- Ensuring the vancomycin infusion is completed 30 minutes before the start of surgery to achieve optimal tissue concentrations
- Monitoring for potential side effects and adjusting the regimen as necessary
- Considering additional measures to prevent surgical site infections, such as meticulous surgical techniques, proper hand hygiene, and perioperative optimization of patient risk factors 1 It's also important to note that clindamycin is another option for patients allergic to beta-lactams, but vancomycin is preferred in cases where MRSA is a concern, given its broader spectrum of activity against this pathogen 1.
From the FDA Drug Label
WARNINGS See BOXED WARNING. Anaphylactic and Severe Hypersensitivity Reactions Anaphylactic shock and anaphylactic reactions have been reported (see ADVERSE REACTIONS) Severe hypersensitivity reactions, including severe skin reactions such as toxic epidermal necrolysis (TEN), drug reaction with eosinophilia and systemic symptoms (DRESS), and Stevens-Johnson syndrome (SJS), some with fatal outcome, have been reported (see ADVERSE REACTIONS)
For a patient who is allergic to Keflex (a type of cephalosporin antibiotic) and requires surgical prophylaxis for post-op ortho, clindamycin can be considered as an alternative option.
- Clindamycin is a lincosamide antibiotic, which is a different class of antibiotics than cephalosporins.
- It is essential to note that clindamycin has its own set of potential side effects and warnings, including the risk of Clostridioides difficile-associated diarrhea (CDAD) and anaphylactic reactions.
- However, if the patient is allergic to Keflex, clindamycin may be a suitable option for surgical prophylaxis, but it should be used with caution and under close monitoring due to its potential side effects 2.
From the Research
Alternative Antibiotics for Surgical Prophylaxis
For patients allergic to Keflex (cephalexin), alternative antibiotics can be used for surgical prophylaxis.
- Cefazolin is a first-line agent for prevention of surgical site infections (SSIs) after total joint arthroplasty, and its use is associated with decreased postoperative SSI without an increase in interoperative hypersensitivity reactions 3.
- Clindamycin serves as an alternative surgical prophylactic antibiotic in patients with penicillin or cephalosporin allergy labels, but its use is associated with higher incidences of surgical site infections (SSIs) 4.
- Vancomycin is another alternative, but its effectiveness may depend on the dosage used, and it may not be as effective as cefazolin or clindamycin in preventing SSIs 5.
Patterns of Prophylactic Postoperative Oral Antibiotic Use
The use of prophylactic postoperative oral antibiotics after foot and ankle surgery is common, with most surgeons prescribing cephalexin 500 mg four times a day for 5 to 7 days 6.
- However, the effectiveness of prophylactic postoperative oral antibiotics in preventing SSIs is not well established, and further studies are needed to determine their efficacy.
Preoperative Antibiotic Prophylaxis Regimens
The use of vancomycin and cefazolin as standard preoperative antibiotic prophylaxis has been shown to reduce revision surgeries for postoperative infection (SSI) and the need for revisions overall 7.
- This regimen may be effective in reducing SSIs following instrumented spinal fusions, but further studies are needed to confirm its effectiveness in other surgical procedures.