Increased Rate of Early Periprosthetic Joint Infection in Total Hip Arthroplasty With the Use of Alternatives to Cefazolin Despite Additional Gram-Negative Coverage

Cefazolin is Associated with a Lower Periprosthetic Joint Infection Risk than Alternative Antibiotic Regimens Following Total Hip Arthroplasty

INTRODUCTION

There have been conflicting reports on the risk of periprosthetic joint infection (PJI) with the use of alternative antibiotics to cefazolin following arthroplasty. We leveraged recent data from a nationally representative multi-payer dataset to investigate this question.

METHODS

We queried a healthcare dataset from 2016 to 2022 to identify primary total hip arthroplasties (THAs) using Current Procedural Terminology (CPT) and International Classification of Disease-Procedure Coding System (ICD-PCS) codes (27130, 0SR90xx, 0SRB0xx) with a corresponding osteoarthritis diagnosis (International Classification of Disease-Clinical Modification (ICD-CM): M16). Patient demographics, characteristics, and outcomes were extracted from existing dataset variables. The PJIs were defined using ICD-10 diagnosis codes from the Centers for Medicare & Medicaid Services' procedure-specific complication measure within 90 days of surgery. We compared PJI between patients receiving cefazolin antibiotic prophylaxis and patients who received an alternative antibiotic or cefazolin plus another antibiotic. The association between cefazolin use and PJI was evaluated using multinomial logistic regression. This study included 289,369 primary THA patients from 2016 to 2022. There were 25,164 patients (8.7%) who received a non-cefazolin antibiotic, 200,367 (69.2%) received cefazolin only, and 63,838 (22.1%) received cefazolin plus an alternative antibiotic.

RESULTS

In univariate analysis, there was a significant difference in the rate of 90-day PJI between the non-cefazolin group, cefazolin only, and cefazolin plus other antibiotic group (0.9, 0.5, and 0.5%, respectively, P < 0.001). In a logistic regression analysis that adjusted for age, sex, payer, race, ethnicity, and Elixhauser Comorbidity Index, the use of cefazolin only and cefazolin plus other antibiotic, were associated with reduced risk of 90-day PJI [OR (odds ratio) 0.62, 95% CI (confidence interval) (0.53 to 0.72), P < 0.001] and [OR 0.64, 95% CI (0.54 to 0.76), P < 0.001].

CONCLUSIONS

In this nationally representative multi-payer study using recent data, patients who received antibiotic prophylaxis with cefazolin had lower 90-day rates of PJI compared to those receiving alternative antibiotics during primary total hip arthroplasty.

Hidden costs of first choice alternatives: A financial model of thromboprophylaxis and prosthetic joint infection prophylaxis in total knee arthroplasty

Background

Aspirin has been shown to be equally or more effective than factor Xa inhibitors for thromboprophylaxis following total knee arthroplasty (TKA). Cefazolin has been proven more effective than vancomycin in preventing prosthetic joint infection (PJI) after TKA. This study aimed to compare costs between different drug combinations for prevention of venous thromboembolism (VTE) and PJI following TKA, focusing on costs associated with PJI management.

Methods

We used published PJI rates for TKA patients treated with aspirin or factor Xa inhibitors for thromboprophylaxis, as well as for those who received prophylactic cefazolin or vancomycin. Unit prices for each drug and labor costs associated with vancomycin administration were obtained from our hospital's pharmacy service. The PJI cost model included the price of 2-stage septic TKA revision and national projections of future TKA volume.

Results

The least expensive average per-patient cost resulted from the combination of aspirin and cefazolin, equating to $521.19 given a 0.8 % PJI rate. The most expensive average per-patient cost was the combination of a factor Xa inhibitor and vancomycin, equaling $5,714.96 given a 1.8 % PJI rate. This extrapolates to an annual cost burden of $19.5 billion by 2040.

Conclusion

The average per-patient cost of using a combination of a factor Xa inhibitor and vancomycin is 711 % greater than the combination of aspirin and cefazolin. In this era of value-based care, aspirin and cefazolin should be considered gold standards for TKA thromboprophylaxis and PJI prophylaxis, as they reduce costs and improve patient outcomes.

[Perioperative antibiotic prophylaxis in obesity]

BACKGROUND

In terms of perioperative infections, arthroplasty for obese patients represents a high-risk procedure. Correct antibiotic prophylaxis is a central pillar of infection prophylaxis. Studies showed increased infection rates if an antibiotic other than cefazolin was administered for prophylaxis. In patients with anamnestic penicillin allergy, an existing allergy is extremely rare, and the presence of cross-allergies to cephalosporins is similarly rare. Consequently, every effort should be made to administer a first- or second generation cephalosporin such as cefazolin.

DOSAGE

Whether the dosage of antibiotic prophylaxis should be adjusted to the body weight remains unclear due to the limited data available: case series showed increased infection rates when cefazolin was underdosed and recommended increasing the dose to 3 g if the body weight exceeds 120 kg. However, no studies with a higher level of evidence exist. Published studies on the effective antibiotic levels in the tissue remain contradictory with regard to possible weight-dependent dose adjustments. Similarly, there is insufficient data on whether local intraoperative antibiotic prophylaxis may be useful in obese patients. By contrast, there is no evidence for a positive benefit of double prophylaxis with two different antibiotics or prolonged postoperative antibiotic prophylaxis in obesity.

CONCLUSION

In summary, the data on antibiotic prophylaxis is generally insufficient, especially when focussing on possible dose adjustments in obesity. The well-timed administration of a cephalosporin such as cefazolin represents the golden standard in orthopedics and trauma surgery. A possible dose adjustment to 3 g for a body weight over 120 kg appears reasonable considering the low costs and the broad therapeutic window and is therefore recommended in the current AWMF S3 guideline.

A nurse-driven penicillin allergy risk score in the preoperative setting was associated with increased cefazolin use perioperatively

STUDY OBJECTIVE

To characterize and assess the effects of a preoperative, nurse-driven penicillin allergy risk stratification tool on rates of perioperative cefazolin and second-line antibiotic use.

DESIGN

Quasi-experimental quality improvement study of penicillin-allergic surgical patients undergoing procedures for which cefazolin is indicated.

SETTING

Outpatient Perioperative Care Clinic (PCC) for preoperative surgical patients at a tertiary care center.

PATIENTS

670 and 1371 adult penicillin-allergic PCC attendants and non-attendants, respectively.

INTERVENTION

A paper penicillin allergy risk stratification questionnaire was administered during the PCC visit. Nurses were educated on its use.

MEASUREMENTS

Antibiotic (cefazolin, clindamycin, vancomycin) use rates in the 24 months before and 17 months after intervention implementation in November 2020 (November 2018 - April 2022) were assessed in penicillin-allergic PCC attendants with statistical process control charts. Multivariable logistic regression assessed antibiotic use rates pre- and post-intervention adjusting for age, sex, surgical specialty and penicillin allergy history severity. Similar analyses were done in penicillin-allergic PCC non-attendants.

MAIN RESULTS

Of 670 penicillin-allergic PCC attendants, 451 (median [IQR] age, 66 (Sousa-Pinto et al., 2021 [14])) were analyzed pre-intervention and 219 (median [IQR] age, 66 (Mine et al., 1970 [13])) post-intervention. One month after implementation, process measures demonstrated an upward shift in cefazolin use for PCC attendants versus no shift or other special cause variation for PCC non-attendants. There were increased odds of cefazolin use (aOR 1.67, 95% CI [1.09-2.57], P = 0.019), decreased odds of clindamycin use (aOR 0.61, 95% CI [0.42-0.89], P = 0.010) and decreased odds of vancomycin use (aOR 0.56, 95% CI [0.35-0.88], P = 0.013) in PCC attendants post-intervention. This effect did not occur in PCC non-attendants. There was no increase in perioperative anaphylaxis post-intervention.

CONCLUSIONS

A simple penicillin allergy risk stratification tool implemented in the preoperative setting was associated with increased use of cefazolin and decreased rates of second-line agents post implementation.