Studies have shown there is minimal risk of cephalosporin cross-reactivity with penicillin (PCN), though avoidance in practice still occurs. Avoidance of cephalosporins due to reported PCN allergies can result in negative clinical outcomes. Removal of cross-reactivity alerts from the electronic health record (EHR) may increase cephalosporin utilization. The objective of this study was to evaluate cephalosporin utilization in those with documented intermediate-, high-, and severe-risk allergies following an EHR cross-reactivity alert removal. This was a retrospective, observational, pre-post review of patients with a documented intermediate-, high-, or severe-risk PCN allergy who received at least one dose of a systemic antibiotic for an indication in which a cephalosporin was first line. An EHR alert removal was implemented along with system-wide guideline updates and education. The primary outcome was the rate of cephalosporin utilization. Secondary outcomes included rates of PCN utilization, antibiotic adverse effects, and a composite of treatment failure. A total of 235 patients were included (pre = 118, post = 117). Intermediate-risk allergies made up a majority of the population (74%), with surgical site infection prophylaxis being the most common antibiotic indication (63%). Cephalosporin utilization significantly increased after alert removal (27% vs 67%, P < 0.001). Use of cefazolin increased by 47% (P < 0.001), while use of alternative agents, clindamycin and vancomycin, decreased by 12.5% (P = 0.032) and 13.4% (P = 0.021), respectively. No patients had an allergic reaction to cephalosporins. Removal of a PCN-cephalosporin cross-reactivity alert from the EHR increased cephalosporin utilization without adverse allergy-related sequelae in those with intermediate- and high-risk PCN allergies.

Background Pancreaticoduodenectomy (PD) is associated with high postoperative morbidity, particularly infectious complications. In patients undergoing preoperative biliary drainage (PBD), bile contamination is common and may lead to a mismatch between standard cephalosporin-based prophylaxis and biliary pathogens. Methods We conducted a retrospective single-center cohort study including 65 patients undergoing PD between December 2021 and May 2025. Of these, 42/65 (64.6%) underwent PBD. Patients received perioperative antibiotic prophylaxis with cefazolin or piperacillin/tazobactam plus fluconazole, according to institutional protocols. Intraoperative bile cultures were obtained in 44/65 patients, yielding 39 positive cultures with multiple isolates. Infectious complications and major morbidity (Clavien-Dindo > IIIA) were assessed. Multivariable logistic regression was performed to identify predictors of infectious complications, with subgroup analysis in drained patients. Results Positive bile cultures were observed in 38/42 (90.5%) drained patients compared with 1/23 (4.3%) non-drained patients (p<0.001). A total of 39 positive bile cultures yielded multiple isolates, including Enterococcus spp. in 24/39 (61.5%) cultures and Candida spp. in 10/39 (25.6%) cultures. Cefazolin did not provide coverage for at least one isolate in 30/39 (76.9%) cultures, compared with 13/39 (33.3%) for piperacillin/tazobactam plus fluconazole. In multivariable analysis restricted to drained patients, piperacillin/tazobactam plus fluconazole was independently associated with fewer infectious complications (odds ratio (OR): 0.13; 95% confidence interval (CI): 0.02-0.92; p=0.041). Conclusions In patients undergoing PD after PBD, bile contamination is frequent and characterized by enteric organisms and a relevant fungal component. Under these conditions, cefazolin prophylaxis shows a high rate of expected non-coverage, whereas piperacillin/tazobactam plus fluconazole provides broader microbiological coverage and is associated with reduced infectious complications. These findings support a tailored prophylactic strategy based on biliary colonization in PBD patients.

Open fractures represent high acuity injuries requiring rapid evaluation and management for optimal outcomes. In this report, we discuss a patient presenting with an open fracture of the proximal phalanx of the right thumb with interphalangeal (IP) joint dislocation. The patient reported that the injury occurred in the setting of trauma from catching a cricket ball, experiencing immediate severe pain and bleeding. Key interventions in the emergency department included rapid x-ray evaluation of the injury, administration of cefazolin and tetanus vaccine, pain control, covering the exposed bone in moist gauze, and involvement of the hand surgery team for bedside irrigation and reduction. He underwent open reduction and internal fixation of the fracture the next day. He was followed in the hand clinic and was doing well at the 12-week appointment. In summary, we report on an open fracture and dislocation of the proximal phalanx of the thumb secondary to a traumatic cricket injury. Early mobilization of the surgical team and adjunctive prophylaxis with cefazolin and updated tetanus were key measures in the emergency department for achieving optimal outcomes.

Extended-spectrum β-lactamases (ESBLs) constitute one of the principal mechanisms underlying multidrug resistance (MDR) in avian pathogenic Escherichia coli (APEC). The coexistence of ESBL-encoding genes, particularly blaCTX-M, together with the plasmid-mediated colistin resistance gene mcr-1 in APEC raises serious concern, as it undermines the effectiveness of third-generation cephalosporins and colistin. To clarify the current epidemiological status and potential transmission risks associated with the co-occurrence of ESBL and mcr-1 genes in southern Xinjiang, 133 liver samples from chickens that had died after exhibiting clinical signs consistent with colibacillosis were collected, from which 100 of these isolates (75.2%, 100/133) were confirmed as APEC. The double-disk diffusion test revealed that 65 strains (65.0%, 65/100) were ESBL-producing. Among these ESBL-producing APEC isolates, resistance rates to ampicillin, cefazolin, ceftiofur, and cefoxitin were 100% (65/65), 100% (65/65), 92.3% (60/65), and 4.6% (3/65, intermediate/susceptible), respectively. PCR detection revealed that 95.4% (62/65) carried blaCTX-M and 93.8% (61/65) carried blaTEM and five isolates (7.7%, 5/65) were resistant to colistin and carried the mcr-1 gene. Integron analysis revealed that int1 was detected in 98.5% (64/65) of the ESBL-APEC isolates. Notably, all five mcr-1-positive strains co-harbored int1. These five isolates exhibited MDR phenotypes and were assigned to phylogenetic groups A (n = 1), B1 (n = 3), and D (n = 1). Whole-genome sequencing (WGS) revealed that the five mcr-1-positive APEC strains belonged to four sequence types (STs): ST6792 (n = 1), ST1196 (n = 2), ST155 (n = 1), and ST162 (n = 1), and harbored three blaCTX-M subtypes (blaCTX-M-55 [n = 3], blaCTX-M-64 [n = 1], and blaCTX-M-65[n = 1]). Furthermore, these strains carried IncI2 or IncFIB plasmid replicons alongside the int1 integrase gene, highlighting the co-occurrence of critical resistance determinants with mobile genetic elements known to facilitate horizontal dissemination. The coexistence of blaCTX-M and mcr-1 in high-risk clones such as ST155 and ST162, which are associated with human infections worldwide, indicates that the region faces a threat from multidrug-resistant strains and a potential risk of cross-species transmission. Given the limited geographic scope and sample size, our findings should be considered a preliminary warning. Future studies with expanded sampling and experimental validation of horizontal transfer are needed to fully assess the transmission risks.

We aimed to identify risk factors for the development of acute kidney injury (AKI) during treatment of Staphylococcus aureus bacteremia (SAB), with particular emphasis on the roles of cloxacillin and cefazolin, and the contribution of other antibiotics. We performed a retrospective, observational, single-center study of a prospective cohort of patients with SAB receiving cloxacillin or cefazolin as definitive therapy and with serum creatinine available at baseline and days 5, 10, and 15. The primary outcome was the highest AKI stage between days 5 and 15; the secondary outcome was 30 day mortality. Univariate and multivariate analyses were performed to identify independent predictors of outcomes. A total of 470 patients were included in the study, and 103 (21.9%) developed AKI during hospitalization. Independent predictors of AKI were age >64 years (adjusted odds ratio [aOR] 1.76; 95% CI 1.08-2.87), peripheral arterial disease (aOR 2.23; 95% CI 1.02-4.88), chronic kidney disease (aOR 3.77; 95% CI 2.07-6.89), need of mechanical ventilation (aOR 3.33; 95% CI 1.62-6.86), and cloxacillin as definitive treatment with prior glycopeptide exposure (aOR 3.45; 95% CI 1.74-6.84). AKI occurred in 42.6% (23/52) of patients receiving empirical glycopeptide followed by cloxacillin, compared with 21.0% (61/290) in those treated with cloxacillin without prior glycopeptide exposure. The development of AKI during admission was an independent predictor of 30 day mortality (aOR 3.50; 95% CI 1.88-6.52). The only modifiable factor associated with AKI was the use of cloxacillin as definitive therapy after prior exposure to glycopeptides. These data reinforce the need to consider non-nephrotoxic alternatives.