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.
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