Higher risk of revision for infection using systemic clindamycin prophylaxis than with cloxacillin

Abstract

Background and purposeClindamycin has not been compared with other antibiotics for prophylaxis in arthroplasty. Since 2009, the Swedish Knee Arthroplasty Register (SKAR) has been collecting information on the prophylactic antibiotic regime used at every individual operation. In Sweden, when there is allergy to penicillin, clindamycin has been the recommended alternative. We examined whether there were differences in the rate of revision due to infection depending on which antibiotic was used as systemic prophylaxis.Patients and methodsPatients who had a total knee arthroplasty (TKA) performed due to osteoarthritis (OA) during the years 2009–2015 were included in the study. Information on which antibiotic was used was available for 80,018 operations (55,530 patients). Survival statistics were used to calculate the rate of revision due to infection until the end of 2015, comparing the group of patients who received cloxacillin with those who received clindamycin as systemic prophylaxis.ResultsCloxacillin was used in 90% of the cases, clindamycin in 7%, and cephalosporins in 2%. The risk of being revised due to infection was higher when clindamycin was used than when cloxacillin was used (RR =1.5, 95% CI: 1.2–2.0; p = 0.001). There was no significant difference in the revision rate for other causes (p = 0.2).InterpretationWe advise that patients reporting allergic reaction to penicillin should have their allergic history explored. In the absence of a clear history of type-I allergic reaction (e.g. urticaria, anaphylaxis, or bronchospasm), we suggest the use of a third-generation cephalosporin instead of clindamycin as perioperative prophylaxis when undergoing a TKR. No recommendation can be given regarding patients with type-1 allergy.

Risk Factors for Septic Arthritis After Anterior Cruciate Ligament Reconstruction: A Nationwide Analysis of 26,014 ACL Reconstructions

“…This is a novel finding in the ACLR setting. Robertsson and colleagues 26 reported similar results when analyzing the results after total knee arthroplasty, where clindamycin compared with cloxacillin increased the risk of revision due to infection by 50%. In Sweden, clindamycin is often used when the patient reports an allergy to penicillin.…”

Who needs penicillin allergy testing?

“…There are more surgical site infections when penicillins are not used when they are the prophylactic antibiotic of choice. 8,20 There are more deaths and inferior outcomes when penicillins are not used in the setting of methicillinsensitive Staphylococcus aureus bacteremia. 3,4 Patients with penicillin allergy spend more time in the hospital, are exposed to significantly more antibiotics associated with Clostridioides difficile and vancomycin-resistant enterococci, and have increased hospital use.…”

“…Penicillins often lead to improved outcomes as first-line agents for many infectious disease processes, including dental, skin, and bloodstream infections. [1][2][3][4][5][6][7][8] Choosing Wisely, an initiative of the American Board of Internal Medicine Foundation, recommends, "Don't overuse non −b-lactam antibiotics in patients with a history of penicillin allergy, without an appropriate evaluation." [9][10][11][12] However, many patients do not undergo evaluation for their penicillin allergy, and exactly what constitutes an appropriate evaluation has changed during the past decade.…”

What’s New in Musculoskeletal Infection

“…Other authors advocated for a universal decolonization protocol involving 25 mL of 4% antimicrobial CHG for 5 days, instead of screening and decolonization with 5 days of intranasal mupirocin (twice daily) and chlorhexidine body wash 22 . Antimicrobial prophylaxis with clindamycin was associated with an increased infection risk compared with cloxacillin and cephalosporins 23 . The use of antimicrobial cement was effective in continued reducing the rate of infection after revision total knee arthroplasty but not primary total knee arthroplasty 24 .…”