Background Cefazolin is a first-line agent for prevention of surgical site infections (SSIs) after total joint arthroplasty. Patients labeled as allergic to beta-lactam antibiotics frequently receive clindamycin or vancomycin perioperatively due to the perceived risk of a hypersensitivity reaction after exposure to cefazolin. Methods This single-system retrospective review included patients labeled as allergic to penicillin or cephalosporin antibiotics and underwent a primary total hip and/or knee arthroplasty between January 2020 and July 2021. A detailed chart review was performed to compare the frequency of SSI within 90 days of surgery and interoperative hypersensitivity reactions (HSRs) between patients receiving cefazolin and patients receiving clindamycin and/or vancomycin. Results A total of 1,128 hip and/or knee arthroplasties from 1,047 patients were included in the analysis (cefazolin n = 809, clindamycin/vancomycin n = 319). More patients in the clindamycin and/or vancomycin group had a history of cephalosporin allergy and allergic reactions with immediate symptoms. There were fewer SSIs in the cefazolin group compared to the clindamycin and/or vancomycin group (0.9% vs. 3.8%, p < .001) including fewer prosthetic joints infections (0.1% vs. 1.9%). Frequency of interoperative HSRs were not different between groups, (cefazolin = 0.2% vs. clindamycin/vancomycin = 1.3%, p = .06). Conclusions The use of cefazolin as a perioperative antibiotic for infection prophylaxis in total joint arthroplasty in patients labeled beta-lactam allergic is associated with decreased postoperative SSI without an increase in interoperative HSR.
Background Prosthetic joint infection (PJI) is a devastating complication following knee and hip arthroplasty. Perioperative antibiotics are routinely used in an effort to decrease the risk of surgical site infections (SSI), including superficial skin infections and deep PJI. The American Academy of Orthopedic Surgeons recommend cefazolin as standard of care for SSI prophylaxis. However, non-beta-lactams are often used in patients labeled as allergic to penicillins or cephalosporins due to concern of increased hypersensitivity reactions (HSR). Methods This study examined the frequency of SSI and HSR after receipt of perioperative cefazolin compared to clindamycin and/or vancomycin (C/V) within adult patients labeled as allergic to penicillins or cephalosporins. Patients were included if they underwent primary total hip or knee replacement surgery between January 2020 and July 2021 within the University of Colorado Health system. The outcome of SSI was assessed up to 90 days after surgery. The outcome of HSR was assessed up to 60 minutes after the conclusion of surgery. Results The cohort included 1,128 patients (cefazolin, n=809; C/V, n=319). Baseline characteristics were similar between groups except the proportion of patients with a history of immediate allergy symptoms was greater in the C/V group (59.6%) compared to the cefazolin group (35.8%). The frequency of SSI was lower in the cefazolin group compared to the C/V group (0.9% vs. 3.8%, p < .01). The cefazolin group included 7 SSI, consisting of 6 superficial SSI and 1 deep PJI. The C/V group included 12 SSI, consisting of 6 superficial SSI and 6 deep PJI. HSR were not significantly different between patients receiving cefazolin vs. C/V (0.2% vs. 1.3%, p=.06). HSR in the cefazolin group consisted of skin involvement (n=1) and self-reported allergy in post-operative window (n=1). Both patients had a non-descript history of penicillin allergy. HSR in the C/V group consisted of skin involvement (n=2) and hemodynamic instability (n=2). Three of the four patients had a history of immediate cephalosporin allergy. Conclusion Among penicillin or cephalosporin allergic patients, the use of cefazolin was associated with a lower frequency of PJI without an increase in HSR during surgery. Disclosures All Authors: No reported disclosures.
Background Perioperative antibiotics reduce surgical site infections after hip and knee arthroplasty. Clindamycin is routinely used as a perioperative antibiotic in patients with beta-lactam allergy labels instead of first-line antibiotics like cefazolin. The purpose of this study is to assess the risk of adverse outcomes associated with the use of clindamycin to prevent surgical site infections (SSI) after total joint arthroplasty. Methods This retrospective review included adult patients labeled as allergic to penicillin or cephalosporin antibiotics, who underwent a primary total hip and/or knee arthroplasty between January 2020 through July 2021, and received perioperative antibiotics. The outcomes of SSI and Clostridioides difficile infection (CDI) within 90 days was compared between patients receiving perioperative clindamycin vs. non-clindamycin antibiotics. Results A total of 1,121 surgical procedures in 1,047 patients were included. The frequency of SSI for the cohort was 1.6% and CDI was 0.4%. SSI occurred more frequently in the clindamycin group than in the non-clindamycin group (4.3% vs 0.7%, p< .01). The average duration from surgery to SSI was 22.7 ± 11.6 days in the clindamycin group and 24.8 ± 11.1 days in the non-clindamycin group. The frequency of CDI occurrence was greater in the clindamycin group than the non-clindamycin group (1.1% vs. 0.1%, p=.05). The average duration from surgery to CDI was 32.6 + 26.6 days in the clindamycin group and 4.6 days in the non-clindamycin group. Multivariable logistic regression identified clindamycin-containing perioperative antibiotic regimens (odds ratio (OR) 5.5) and opioid use prior to surgery (OR 8.7) as risk factors for 90-day surgical site infection. Staphylococcus aureus was the cultured pathogen in 9 of the 17 SSIs. Conclusion This study found a significantly higher frequency of SSI and CDI when clindamycin-based regimens are used perioperatively for primary hip and knee arthroplasty. These results are likely related to decreased activity of clindamycin against Staphylococcus aureus and greater alterations of the microbiome in comparison to beta-lactams. Disclosures All Authors: No reported disclosures.
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