Cefazolin remains the linchpin for preventing acute periprosthetic joint infection following primary total knee arthroplasty

Abstract

Aims Despite recent literature questioning their use, vancomycin and clindamycin often substitute cefazolin as the preoperative antibiotic prophylaxis in primary total knee arthroplasty (TKA), especially in the setting of documented allergy to penicillin. Topical povidone-iodine lavage and vancomycin powder (VIP) are adjuncts that may further broaden antimicrobial coverage, and have shown some promise in recent investigations. The purpose of this study, therefore, is to compare the risk of acute periprosthetic joint infection (PJI) in primary TKA patients who received cefazolin and VIP to those who received a non-cephalosporin alternative and VIP. Methods This was a retrospective cohort study of 11,550 primary TKAs performed at an orthopaedic hospital between 2013 and 2019. The primary outcome was PJI occurring within 90 days of surgery. Patients were stratified into two groups (cefazolin vs non-cephalosporin) based on their preoperative antibiotic. All patients also received the VIP protocol at wound closure. Bivariate and multiple logistic regression analyses were performed to control for potential confounders and identify the odds ratio of PJI. Results In all, 10,484 knees (90.8%) received cefazolin, while 1,066 knees (9.2%) received a non-cephalosporin agent (either vancomycin or clindamycin) as preoperative prophylaxis. The rate of PJI in the cefazolin group (0.5%; 48/10,484) was significantly lower than the rate of PJI in the non-cephalosporin group (1.0%; 11/1,066) (p = 0.012). After controlling for confounding variables, the odds ratio (OR) of developing a PJI was increased in the non-cephalosporin cohort compared to the cefazolin cohort (OR 2.389; 1.2 to 4.6); p = 0.01). Conclusion Despite the use of topical irrigant solutions and addition of local antimicrobial agents, the use of a non-cephalosporin perioperative antibiotic continues to be associated with a greater risk of TKA PJI compared to cefazolin. Strategies that increase the proportion of patients receiving cefazolin rather than non-cephalosporin alternatives must be emphasized. Cite this article: Bone Jt Open 2022;3(1):35–41.

The Impact of Patient-Reported Penicillin or Cephalosporin Allergy on the Occurrence of the Periprosthetic Joint Infection in Primary Knee and Hip Arthroplasty

“…Wyles et al [ 5 ] found higher rates of PJI when non-cephalosporin prophylactic antibiotics were used following primary TKA and THA. Buchalter et al [ 12 ] also reported a significantly higher PJI rate after TKA in a non-cephalosporin cohort in their hospital. Nationwide research from Wu et al [ 10 ] did not observe any significant differences in PJI rate between a cephalosporin and non-cephalosporin cohort after THA; they did however report a significant difference in PJI rate after TKA and after shoulder arthroplasty.…”

“…There are some studies to date that have analyzed the influence of different prophylactic antibiotic regimens on PJI rates after arthroplasty surgery [ 22 , 23 , 24 , 25 , 26 ]. However, not many have compared different prophylactic antibiotic regimens adjusted due to reported penicillin or cephalosporin allergy [ 5 , 8 , 10 , 12 , 13 ]. Wyles et al [ 5 ] found higher rates of PJI when non-cephalosporin prophylactic antibiotics were used following primary TKA and THA.…”

“…Previous studies have demonstrated that reporting a penicillin or cephalosporin allergy and the consequent use of a second-line prophylactic antibiotic is associated with significantly higher rates of surgical site infections after various surgical procedures [ 5 , 7 , 8 , 9 ]. However, only a few studies have focused on the impact of patient-reported penicillin or cephalosporin allergy on the PJI rate in joint arthroplasty [ 5 , 8 , 10 , 11 , 12 ]. These studies were not unanimous on the effect of second-line prophylactic antibiotics on the occurrence of PJI [ 5 , 8 , 10 , 12 , 13 ].…”

“…However, only a few studies have focused on the impact of patient-reported penicillin or cephalosporin allergy on the PJI rate in joint arthroplasty [ 5 , 8 , 10 , 11 , 12 ]. These studies were not unanimous on the effect of second-line prophylactic antibiotics on the occurrence of PJI [ 5 , 8 , 10 , 12 , 13 ]. The current evidence regarding the superiority of cephalosporin to non-cephalosporin alternatives therefore remains limited.…”

Risk Factors for Periprosthetic Joint Infection after Primary Total Knee Arthroplasty

“…Muwanis et al found that dilute povidone-iodine (Betadine, Avrio Health L.P, Stamford, CT, USA) compared with normal saline irrigation is an economical and simple technique to reduce PJI and more specifically SSI in TKA [ 57 ]. According to Buchalter et al, in spite of the utilization of topical irrigation solutions and addition of local antimicrobial agents, the use of a non-cephalosporin perioperative antibiotic (either vancomycin or clindamycin) is related to a higher risk of TKA PJI compared with cefazolin [ 58 ]. An increased frequency of PJI in individuals experiencing mobilization under anesthesia (MUA) was reported by Parkulo et al [ 59 ].…”