Perioperative Cefazolin for Total Joint Arthroplasty Patients Who Have a Penicillin Allergy: Is it Safe?

Brandon R Bukowski; Ricardo J Torres-Ramirez; Daniel Devine; Yu-Fen Chiu; Alberto V Carli; Daniel B Maalouf; Enrique A Goytizolo; Andy O Miller; Jose A Rodriguez

doi:10.1016/j.arth.2024.04.058

Perioperative Cefazolin for Total Joint Arthroplasty Patients Who Have a Penicillin Allergy: Is it Safe?

J Arthroplasty. 2024 Apr 25:S0883-5403(24)00381-4. doi: 10.1016/j.arth.2024.04.058. Online ahead of print.

Authors

Brandon R Bukowski¹, Ricardo J Torres-Ramirez¹, Daniel Devine¹, Yu-Fen Chiu², Alberto V Carli¹, Daniel B Maalouf³, Enrique A Goytizolo³, Andy O Miller⁴, Jose A Rodriguez¹

Affiliations

¹ Department of Orthopedic Surgery, Hospital for Special Surgery, 535 E. 70th Street, New York, NY 10021.
² Biostatistics Core, Hospital for Special Surgery, 535 E. 70th Street, New York, NY 10021.
³ Department of Anesthesiology, Hospital for Special Surgery, 535 E. 70th Street, New York, NY 10021.
⁴ Department of Internal Medicine, Division of Infectious Disease, Hospital for Special Surgery, 535 E. 70th Street, New York, NY 10021.

PMID: 38677347
DOI: 10.1016/j.arth.2024.04.058

Abstract

Background: Cefazolin is the standard of care for perioperative antibiotic prophylaxis in total joint arthroplasty (TJA) in the United States. The potential allergic cross-reactivity between cefazolin and penicillin causes uncertainty regarding optimal antibiotic choice in patients who have a reported penicillin allergy (rPCNA). The purpose of this study was to determine the safety of perioperative cefazolin in PCNA patients undergoing primary TJA.

Methods: We identified all patients (n = 49,842) undergoing primary total hip arthroplasty (n = 25,659) or total knee arthroplasty (n = 24,183) from 2016 to 2022 who received perioperative intravenous antibiotic prophylaxis. Patients who had a rPCNA (n = 5,508) who received cefazolin (n = 4,938, 89.7%) were compared to rPCNA patients who did not (n = 570, 10.3%), and to patients who did not have a rPCNA (n = 43,359). The primary outcome was the rate of allergic reactions within 72 hours postoperatively. Secondary outcomes included the rates of superficial infections, deep infections, and Clostridioides difficile infections within 90 days.

Results: The rate of allergic reactions was 0.1% (n = 5) in rPCNA patients who received cefazolin, compared to 0.2% (n = 1) in rPCNA patients who did not (P = 0.48) and 0.02% (n = 11) in patients who have no rPCNA (P = 0.02). Allergic reactions were mild in all 5 rPCNA patients who received cefazolin and were characterized by cutaneous symptoms (n = 4) or dyspnea in the absence of respiratory distress (n = 1) that resolved promptly with antibiotic discontinuation and administration of antihistamines and/or corticosteroids. We observed no differences in the rates of superficial infections (0.1 versus 0.2%, P = 0.58), deep infections (0.3 versus 0.4%, P = 0.68), or C. difficile infections (0.04 versus 0%, P = 0.99) within 90 days in rPCNA patients who received cefazolin versus alternative perioperative antibiotics.

Conclusion: In this series of over 5,500 patients who had a rPCNA undergoing primary TJA, perioperative prophylaxis with cefazolin resulted in a 0.1% incidence of allergic reactions that were clinically indolent. Cefazolin can be safely administered to most patients, independent of rPCNA severity.

Keywords: antibiotic allergic reactions; cephalosporins; penicillin allergy; total hip arthroplasty; total knee arthroplasty.