Cefazolin vs Second-line Antibiotics for Surgical Site Infection Prevention After Total Joint Arthroplasty Among Patients With a Beta-lactam Allergy

Abstract

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.

Using antibiotics wisely

“…Clindamycin also has an increased risk of C. difficile infection in this population [62 ▪ ]. Norvell et al confirmed that using cefazolin over a second line antimicrobial prophylaxis in total hip or knee arthroplasties had fewer SSI (0.9% vs 3.8%; P < .001) and PJI (0.1% vs 1.9%) [59 ▪▪ ]. With the new practice recommendations for drug allergy from the American Academy of Allergy, Asthma, and Immunology (AAAAI) [64 ▪ ] and the documented safety of direct oral amoxicillin challenge on delabelling penicillin allergies [65,66 ▪ ], this should be a major target in using antibiotics wisely to improve antibiotic use and prevent SSI.…”

“…Penicillin allergy reporting significantly impacted antibiotic usage in surgical prophylaxis with more use of second line antibiotic prophylaxis [59 ▪▪ ]. It has been well described that penicillin allergies are over-reported, and that cross reactions with cefazolin does not occur due to side chain differences [60].…”

Antibiotic Stewardship in Surgical Departments

“…A thorough allergy history is necessary: it is problematic that in a recent U.K. study, in two-thirds of patients with documented penicillin allergy, there were no details recorded [4]. Patients who report a β-lactam allergy are at higher risk of SSIs and C. difficile infection due to the use of alternative broad-spectrum and often inferior antibiotics [4,33,55,56]. Among these patients, only a small proportion have a true allergy, and the proper tools should be utilized for the delabeling [55,56].…”

“…Patients who report a β-lactam allergy are at higher risk of SSIs and C. difficile infection due to the use of alternative broad-spectrum and often inferior antibiotics [4,33,55,56]. Among these patients, only a small proportion have a true allergy, and the proper tools should be utilized for the delabeling [55,56].…”

Management of Penicillin Allergy in the Perioperative Setting

“…Multiple studies have identified an increased SSI risk in penicillin-allergic patients with the use of beta-lactam alternatives for perioperative prophylaxis, which is present across multiple procedure types, including orthopedic surgeries, oral and maxillofacial surgeries, obstetric procedures and gynecologic surgeries, colorectal surgeries, and cardiac surgeries [4][5][6][7][8][9]. Blumenthal et al found that penicillin-allergic patients had an adjusted odds ratio of 1.51 (95% CI 1.02-2.22) for developing an SSI following a surgical procedure compared to those without a reported allergy, which they attributed to the use of antibiotics other than cefazolin in these patients [9].…”