Guideline-concordant cefazolin prophylaxis in penicillin allergy labeled arthroplasty patients: Progress and persistent barriers.

BACKGROUND

Cephalosporins are recommended first-line antibiotic prophylaxis for total joint arthroplasty (TJA). However, penicillin allergy labels (PALs), which are often inaccurate, reduce cephalosporin use. In 2022, AAOS released risk-stratification guidelines based on reaction type to safely increase cephalosporin use in PAL patients, categorizing limited hypersensitivity as low-risk, anaphylaxis/angioedema as moderate-risk, and multiorgan hypersensitivity as high-risk. Cefazolin is recommended for all low-risk and some moderate-risk PAL patients, but guideline adherence remains unclear. We evaluated cefazolin administration rates and adverse drug reaction (ADR) incidence in PAL patients before and after guideline dissemination and explored potential barriers to guideline-concordance.

METHODS

A retrospective review was conducted on PAL patients undergoing primary TJA (total hip arthroplasty (THA), total knee arthroplasty (TKA), and total shoulder arthroplasty (TSA) at an academic center and two affiliated community hospitals between 2013 and 2024. Revisions were excluded. AAOS risk-stratification guidelines were utilized to classify patients and evaluate guideline-concordance. Date of PAL, antibiotic administration utilized for primary arthroplasty, and ADRs were collected.

RESULTS

Of 172 primary TJAs (49 THAs, 72 TKAs, 51 TSAs) from 130 patients, 92 occurred before and 80 after 2022. Cefazolin administration increased from 64% to 88% (p = 0.001) in low-risk and 40% to 64% (p = 0.281) in moderate-risk patients. The main alternative was vancomycin with clindamycin (21%). Mean time from PAL to surgery was 9.9 years. No ADRs occurred with any antibiotic. Among 36 patients undergoing ≥2 TJAs, 72% initially received cefazolin, and 50% who initially received alternatives subsequently received cefazolin without ADRs.

CONCLUSION

Cefazolin administration increased after guideline release, yet hesitancy persisted even in low-risk patients. All PAL patients who received cefazolin tolerated it. Documented PALs continue reducing the likelihood of receiving first-line antibiotic recommendations. PAL documentation quality and timing were identified as potential barriers to guideline-concordance. Targeted initiatives may ensure appropriate, evidence-based TJA prophylaxis.