Understanding Allergies and the Impact on Surgery

As a surgeon, I have had over two decades of experience meeting patients and getting to know them through a thorough history and physical examination. In order for this information to be of greatest value it is vital that the patient provides accurate information. Therefore, understanding your personal health history is critical when it comes to interactions you will have with any health care provider. Spending time going over your history including medical history, previous surgeries, diseases that other family members have had, social history to include smoking, alcohol and drugs as well as current medications including their doses allows the doctor to get to know you and your needs better. It provides insight into how to plan effectively for your care. This information includes being aware of your allergies to medications and the specifics as what reaction you have when you have been exposed to these medications. This information is not only important for your primary care providers but it is also important for surgeons as part of operative planning for you as an individual.

The majority of surgeries have antibiotics recommended as a way of preventing surgical site infections, called surgical prophylaxis. Surgical site infections are areas of inflammation with or without associated drainage at the location where the incision was made for the operation. Sometimes the incisions need to be opened in order to heal leaving a larger wound from which the patient then has to recover. These infections can be very painful as well as costly including extending hospitalizations and causing readmission to the hospital. Therefore, when preparing patients for surgery a great deal of effort is made to optimize them in order to prevent these infections. There are several steps taken to decrease this risk and some examples include preoperative bathing, blood sugar control and choosing the correct antibiotic for the specific surgery planned.

The antibiotic choice is based on the location of the incision as well as the organs that the surgeon will be working on as different bacteria are present in different locations throughout the body. Those bacteria on the skin tend to be the most important as almost all incisions start at the skin level. Guidelines exist that recommend the specific antibiotic, dose and timing of administration and are used throughout the country. The most commonly used antibiotics for this purpose are what are known as first generation cephalosporins. Additionally, antibiotics in the penicillin family may also be used. These are used because they are the most effective at reducing surgical site infection risk while avoiding exposing the patient’s body to an antibiotic whose mechanism would kill off too many bacteria that are normal and needed for the patient to continue a healthy balance. 

Penicillin allergies are relatively commonly documented compared to other medications. Furthermore, there is a small (<1%) cross reactivity with the first-generation cephalosporins commonly used in surgical prophylaxis. The cross reactivity means that if the person is allergic to a penicillin then there is less than 1 in 100 chance that they would have a similar reaction to the first generation cephalopsporin. As a result, for many years health care providers would take at face value that when patients came in claiming a penicillin allergy, alternative antibiotics would be used. However, we now know that many patients are unclear on the definition of allergy and that using alternative antibiotics have led to suboptimal results. Therefore, a patients’ understanding of their own history can help avoid these issues. 

An allergy results from the body reacting to a drug and can often result in hives, an increase in heart rate, or swelling. The major concern with severe allergic reactions is an inability for the patient to breath or for their blood pressure to drop. This is vastly different from what many people consider an allergy- as an example- an upset stomach or nausea. The former is an allergy and the latter is a side effect of the drug. Furthermore, allergies that occurred as a child may not remain as an allergy and allergy testing may help to clarify whether a patient still has a true allergy or not. Finally, allergies are not hereditary. I had a patient tell me that she was allergic to pencillin. When I asked what happened when she took that medication she said she did not know but since her father was allergic she assumed she was allergic as well. Fortunately, others and I have learned to asking more probing questions to ascertain whether patients have a real allergy or not. Moreover, pharmacists and hospitals are making more of an effort to clarify with patients what reactions they have to ensure that they are receiving the correct antibiotic. Allergy testing is more available as well.

In order to optimize outcomes, patients have to embrace their own health care responsibility and truly understand the implications of the information they share. Health care providers can only do their best with the information they have. Ultimately, we all want good outcomes for our patients to allow them to recover quickly and return to their lives as functional members of society. It is in all of our best interest to continue to education each other on these challenging health care issues. Understanding allergies is a key component of allowing us to use the right drug, right dose at the right time which is integral to our antimicrobial stewardship efforts. In order for us to have functional antibiotics in the future that are still effective against the bacteria we face, we all have to take something like this that may seemingly be insignificant- very seriously.