Cefazolin beneficial for infection prevention after total joint arthroplasty in patients allergic to beta-lactams

New research revealed that the use of cefazolin as a perioperative antibiotic for infection prevention in total joint arthroplasty in individuals designated beta-lactam allergic is linked with lower postoperative surgical site infections without an increase in interoperative hypersensitivity reactions. The study was published in the journal Open Forum Infectious Diseases. 

Total joint arthroplasties constitute total knee and hip arthroplasty. As these are the common procedures that are performed, it is necessary to ensure that patients receive the optimal antibiotic regimens to prevent surgical site infections (SSI). SSI, specifically periprosthetic joint infections (PJI), have poor-patient outcomes and are considered a traumatic outcome after a total joint arthroplasty. So prophylactic antibiotics are indicated perioperatively. Cephalosporins, especially cefazolin, are the main drugs of choice for SSI prevention for many surgeries given their wide therapeutic index, activity against both gram-positive and gram-negative bacteria, and ease of administration in perioperative settings. But in patients who are labeled allergic to beta-lactam antibiotics, clindamycin or vancomycin are administered perioperatively due to an apprehended risk of a hypersensitivity reaction after exposure to cefazolin. Hence researchers conducted a single-system retrospective review to compare cefazolin to second-line antibiotics to evaluate the incidence of SSIs within 90 days following joint replacement surgery and interoperative HSRs among patients labeled as allergic to penicillin or cephalosporin. 

Patients labeled as allergic to penicillin or cephalosporin antibiotics and who underwent a primary total hip and/or knee arthroplasty between January 2020 and July 2021 were included in the study. A detailed chart review compared the frequency of SSI within 90 days of surgery and interoperative hypersensitivity reactions (HSRs) between patients receiving cefazolin and those receiving clindamycin and/or vancomycin. 

Key findings: 

• The analysis included a total of 1,128 hip and/or knee arthroplasties from 1,047 patients. There were 809 arthroplasties in the cefazolin group and 319 in the clindamycin/vancomycin group.
• A history of cephalosporin allergy and allergic reactions with immediate symptoms were present more in the clindamycin and/or vancomycin group. 
• Fewer SSIs were noticed in the cefazolin group compared to the clindamycin and/or vancomycin group (0.9% vs. 3.8%, p < .001) including fewer prosthetic joint infections (0.1% vs. 1.9%).
• There was no difference in the frequency of interoperative HSRs between the two groups. 

Thus, cefazolin was shown to have a significantly lower frequency of SSI compared to clindamycin and/or vancomycin without an increased risk of HSR. 

Further reading: Miranda R Norvell, PharmD, and others, Cefazolin vs. second-line antibiotics for surgical site infection prevention after total joint arthroplasty among patients with a beta-lactam allergy, Open Forum Infectious Diseases, 2023; ofad224, https://doi.org/10.1093/ofid/ofad224