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The Impact of Patient-Reported Penicillin Allergy on Risk for Surgical Site Infection in Total Joint Arthroplasty

Stone, Andrea H. MSN, CRNP; Kelmer, Grayson; MacDonald, James H. MD; Clance, Mary R. MD, MPH; King, Paul J. MD

JAAOS - Journal of the American Academy of Orthopaedic Surgeons: November 15, 2019 - Volume 27 - Issue 22 - p 854-860
doi: 10.5435/JAAOS-D-18-00709
Research Article

Background: Penicillin (PCN) allergy is reported in 10% to 20% of the population; studies show that only 1% to 3% of patients have a true allergy. Most patients reporting a PCN allergy receive second-line antibiotic prophylaxis preoperatively, which raises concerns about antimicrobial efficacy. Studies also suggest that second-line antibiotics may increase the rate of surgical site infection (SSI). In this study we aim to analyze the effect of PCN allergy on antibiotic type prescribed and SSI in our total joint arthroplasty population.

Methods: A retrospective review of 4,903 primary total hip and total knee arthroplasty performed from January 2015 to June 2017 in a single institution. A detailed chart review was performed to identify reported reactions and antibiotic prescribed.

Results: Seven hundred ninety-six patients (16.2%) reported a PCN allergy; the reactions were classified into three tiers. Six hundred fifteen patients (12.5%) reported an IgE-mediated allergy, hypersensitivity, or a possible allergy; 89 (1.8%) reported an adverse effect; and 92 (1.9%) had an unknown reaction. Patients reporting a PCN allergy were less likely to receive cefazolin (94.9 versus 6.9%; P < 0.001) and more likely to receive clindamycin (1.1 versus 80.7%; P < 0.001) or vancomycin (4.0 versus 12.4%; P < 0.001). There was no difference in infection rate by reported PCN allergy (0.6 versus 0.4%; P = 0.473) or antibiotic prescribed (0.5 versus 0.6%; P = 0.4817).

Conclusion: No patient with a PCN allergy and given cefazolin experienced a reaction; based on reported reactions, most patients with a PCN allergy can safely receive first-line antibiotic therapy. In this population, PCN allergy and second-line antibiotic therapy did not influence the rate of SSI.

From the Department of Surgical Research (Ms. Stone and Ms. Kelmer), Anne Arundel Medical Center, the Center for Joint Replacement (Dr. MacDonald and Dr. King), Anne Arundel Medical Center, and Anne Arundel Medical Center (Dr. Clance), Annapolis, MD.

Correspondence to Dr. King: pking@osmc.net

None of the following authors or any immediate family member has received anything of value from or has stock or stock options held in a commercial company or institution related directly or indirectly to the subject of this article: Dr. Stone, Kelmer, Dr. MacDonald, Dr. Clance, and Dr. King.

Copyright 2019 by the American Academy of Orthopaedic Surgeons.
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