The Choice of Antibiotic Prophylaxis Influences the Infection Reoperation Rate in Primary Shoulder Arthroplasty: Analysis From the Swedish Shoulder Arthroplasty Register

Abstract

Background Periprosthetic joint infection is a serious complication and a major reason for revision surgery after primary shoulder arthroplasty. The prophylactic antibiotics for primary shoulder arthroplasty that have predominantly been used in Sweden are cloxacillin and clindamycin. To address Cutibacterium acnes, benzylpenicillin has recently increasingly been added to cloxacillin, but it is unclear which antibiotic prophylaxis regimen is the most effective to prevent periprosthetic joint infection. Questions/purposes After controlling for baseline differences among patients such as age, gender, previous surgery, cement fixation, and arthroplasty type, was the risk of reoperation for infection higher in patients who received cloxacillin than in those who received clindamycin or the combination of benzylpenicillin and cloxacillin? Methods Data from the Swedish Shoulder Arthroplasty Register were used for this study. The inclusion criterion was registered antibiotic prophylaxis in primary arthroplasty. Between January 1, 1999, and December 31, 2019, 22,470 primary shoulder arthroplasties, including total shoulder, hemiarthroplasty, and reverse shoulder arthroplasties, were entered into the Swedish Shoulder Arthroplasty Register. Reporting of antibiotic prophylaxis to the register was introduced on January 1, 2013. Since then, the completeness of information on the type of antibiotic prophylaxis in the reports has been 85.3%. Consequently, 10,706 arthroplasties were eligible and fulfilled the inclusion criterion of reported antibiotic prophylaxis. A further 129 were excluded because of unusual prophylaxis regimens, leaving 10,577 shoulder arthroplasties for analysis. The Swedish Shoulder Arthroplasty Register gathers information from all 60 hospitals performing shoulder arthroplasty in Sweden, and through a comparison with the National Patient Register, it has been Each author certifies that there are no funding or commercial associations (consultancies, stock ownership, equity interest, patent/licensing arrangements, etc.) that might pose a conflict of interest in connection with the submitted article related to the author or any immediate family members. All ICMJE Conflict of Interest Forms for authors and Clinical Orthopaedics and Related Research® editors and board members are on file with the publication and can be viewed on request. Because this study was based on data collected from the National Quality Register to report any outcome as feedback to the users, no ethical permit was required. The National Ethical Review Board approved and confirmed this (decision 2022-01148-01).

Cutibacterium avidum: A Potent and Underestimated Pathogen in Prosthetic Hip Joint Infections

“…Since C. acnes is an important etiological agent in shoulder PJIs, benzylpenicillin has increasingly been added to routine prophylaxis with cloxacillin for shoulder prosthetic surgery in Sweden. A register-based study [ 33 ] using data from the Swedish Shoulder Arthroplasty Register found that cloxacillin prophylaxis was associated with a significantly increased relative risk of reoperation for infection compared to the combination of cloxacillin and benzylpenicillin. In addition, since cloxacillin has a short half-life, is highly protein-bound, and the free concentration could be affected by the patient’s BMI, serum albumin, and renal function, it may constitute a risk of subtherapeutic concentrations of cloxacillin during surgery in specific patients.…”

Shoulder & Elbow

“…This study from across Sweden reviewed over 10,000 primary shoulder arthroplasties sourced from patients operated on over seven years, including hemiarthroplasties and anatomical and reverse shoulder arthroplasties, via the Swedish Shoulder Arthroplasty Register. 2 Postoperative infection rates were compared using revision for infection as a surrogate marker, and baseline differences were adjusted for variables such as age, sex, previous surgery, cement fixation, and arthroplasty type. The authors analyzed the association between antibiotic prophylaxis regimens (cloxacillin, clindamycin, or a combination of cloxacillin and benzylpenicillin) and the risk of reoperation for infection.…”