The risk of total shoulder complications is significantly greater in patients with antibiotic allergies - why?

As discussed in the prior post (see this link) preoperative identification of risk factors, such as male sex, for periprosthetic infections (PJI) gives surgeons the opportunity to discuss the risk with the patient before surgery and also to implement extraordinary prophylaxis.

The authors of Total Shoulder Arthroplasty: Antibiotic Allergies Increase Risk of Postoperative Complications, call attention to another risk factor: antibiotic allergy. Using the PearlDiver Patient Records Database they identified 85,606 patients having total shoulder arthroplasty for osteoarthritis of which 7,836 (9.15%) had self-reported antibiotic allergies. They documented patient demographics, comorbidities, 90-day medical complications, and rate of revision at 30 days, 90 days, 1 year, and 2 years.

Univariate analysis found that patients reporting antibiotic allergies were younger, more often female, and more likely to have comorbidities than nonallergic control subjects.

Multivariate analysis found that patients reporting antibiotic allergies had increased likelihood of periprosthetic joint infection (PJI) within 30 days (odds ratio [OR]: 3.129), 1 year (OR: 2.016), and 2 years of surgery (OR: 2.221).

Patients reporting antibiotic allergies had increased likelihood of postoperative anemia (OR: 1.126), blood transfusion (OR: 1.238), and readmission (OR: 1.585) within 90 days of surgery.

Patients with penicillin allergy had a greater incidence of revision due to PJI at 30 days (OR: 4.811), 90 days (OR: 2.91), 1 year (OR: 2.105), and 2 years (OR: 2.72).

Rates of reported antibiotic allergies increased from 2010 to 2018 (8.60% to 10.91%; P = 0.001) in patients undergoing TSA.

Comment: While the reason for the increased rate of periprosthetic infection and other complications in patients with "self-reported" (rather than documented) antibiotic allergies is unclear, some hypotheses come to mind:
(1) "self-reported" antibiotic allergies may lead surgeons to use antibiotics other than cephalosporins, which are maximally effective in preventing periprosthetic infections (see What antibiotic prophylaxis should be used against shoulder periprosthetic infection?) This problem is addressed in When is it safe to give cephalosporin antibiotic prophylaxis to patients who are "allergic to penicillin"?
(2) patients reporting antibiotic allergies are more likely to have an altered bacterial biome as a result of prior antibiotic treatment and are more likely to have had an infection treated with antibiotics - both of which factors may increase their risk of another infection.
(3) self-reporting of antibiotic allergies is associated with an increased rate of many co-morbidities, each of which could increase the risk of periprosthetic infection and other complications.




The conclusion is that patients with "self-reported" antibiotic allergies are at greater risk for infections and other complications, whether or not there was an actually demonstrated allergy. Patients reporting antibiotic allergies deserve extra preoperative, intraoperative and postoperative attention to minimize these risks.

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Here are some videos that are of shoulder interest
Shoulder arthritis - what you need to know (see this link).
How to x-ray the shoulder (see this link).
The ream and run procedure (see this link).
The total shoulder arthroplasty (see this link).
The cuff tear arthropathy arthroplasty (see this link).
The reverse total shoulder arthroplasty (see this link).
The smooth and move procedure for irreparable rotator cuff tears (see this link).
Shoulder rehabilitation exercises (see this link).

Single-Stage Revision Shoulder Arthroplasty - choice of antibiotic treatment

 Oral and IV Antibiotic Administration After Single-Stage Revision Shoulder Arthroplasty Study of Survivorship and Patient-Reported Outcomes in Patients without Clear Preoperative or Intraoperative Infection

Painful and stiff shoulder arthroplasties may come to surgical revision. Because Cutibacterium periprosthetic infection (Cuti PJI) is a common cause of a stiff, painful arthroplasty and because Cuti PJI cannot be reliably diagnosed before or at the time of revision arthroplasty, the surgeon needs to make a decision regarding postoperative antibiotic therapy without knowledge of the results of introperative cultures (which are only finalized weeks after the procedure).

These authors determined infection-free survival, revision-free survival, complications, and patient-reported outcomes for 92 patients selected to receive oral or intravenous (IV) antibiotics after single stage revision arthroplasty. IV antibiotics were administered if the surgeon had a high index of suspicion for infection, and oral antibiotics were given if there was a low suspicion. Factors contributing to a high index of suspicion included young age, male sex, prior infection, prior surgery on the shoulder, humeral loosening or osteolysis, synovitis, and high levels of Cutibacterium on cultures of the unprepared skin over the shoulder. Antibiotic therapy was modified as necessary when the results of intraoperative culture became available. Patient-reported outcomes and adverse events were documented at a mean of 4.1 years.

Patients opting out of the recommended antibiotic protocol and those with obvious infection (e.g., draining sinus, purulence, or multiple cultures positive for virulent bacteria) were excluded from this study given that IV antibiotic treatment was used in all of these patients. 27 patients who did not have 2-year followup were excluded.

In selecting antibiotic therapy, surgeons correctly predicted the presence or absence of multiple positive cultures of specimens from the revision surgery in 72% of the 92 cases. This means that in the great majority of cases, those with multiple positive cultures were assigned to receive intravenous antibiotics and those without multiple positive cultures were assigned to receive oral antibiotics. 

Post-revision antibiotic therapy was associated with an infection-free survival rate of 91% at a mean of  >4 years of follow-up. 

Subsequent re-revision surgery was performed in 17 (18%) of the patients; 8 of these 17 patients had ≥2 positive cultures at re-revision, indicating that the revision and antibiotics failed to resolve the infection. Patients having ≥2 positive cultures at re-revision were more likely to be younger, to be male, and to have been deemed "high risk" for Cutibacterium PJI at the initial revision. 

The IV and oral antibiotic groups had similar postoperative Simple Shoulder Test (SST), American Shoulder and Elbow Surgeons (ASES), and satisfaction scores. 

Patients receiving IV antibiotics had a higher rate of antibiotic-related adverse events. 

10 out of 37 (27%) of patients started on IV antibiotics had complications: 4 had gastrointestinal complications, 3 had dermatologic complications and 3 had other complications. 

12 out of 55 (22%) patients started on oral antibiotics had complications: 3 had gastrointestinal complications, 5 had dermatologic complications, and 4 had other complications. 

While patients requiring a change from oral to IV antibiotics based on positive intraoperative cultures had similar survivorship compared with those initially treated with IV antibiotics, the highest rate of antibiotic related complications - 8 out of 15 (53%) - was seen in patients initially started on oral antibiotics and converted to IV antibiotics when intraoperative cultures turned positive.

Comment: These authors' approach to post-revision antibiotic therapy yielded an infection-free survivorship of 91% at an average of >4 years of follow-up. They were able to predict the presence or absence of ≥2 positive cultures of specimens taken at revision arthroplasty in 72% of the cases. The outcomes of treating patients deemed to be at high risk for Cuti PJI with IV antibiotics were similar to the outcomes of treating patients deemed to be at low risk for Cuti PJI with oral antibiotics. Overall, patients demonstrated a median decrease in the VAS pain score of 4 points and a median improvement in the SSTscore of 3 points, both of which surpass the minimum clinically important difference for these instrument

There are advantages to starting IV antibiotics prior to hospital discharge in patients with a high suspicion for PJI, including increased efficacy of the IV therapy (i.e. consistency of administration and achievement of the desired antibiotic serum levels) and establishment of a peripherally inserted peripheral central catheter (PICC line) before the patient leaves the medical center.  Disadvantages of a PICC line include the cost and the risks of venous throboembolism and catheter migration. 

While the initial use of oral antibiotics may seem more benign, the delayed implementation of IV antibiotics can be difficult to arrange (especially if the patient lives in a city remote from the surgeon's site of practice) and, for reasons that remain unclear, patients started on oral antibiotics and converted to IV antibiotics because of positive cultures have the highest rate of antibiotic related complications.

 Follow on twitter: https://twitter.com/shoulderarth

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Follow on LinkedIn: https://www.linkedin.com/in/rick-matsen-88b1a8133/

How you can support research in shoulder surgery Click on this link.

Here are some videos that are of shoulder interest

Shoulder arthritis - what you need to know (see this link)

Shoulder arthritis - x-ray appearance (see this link)

The smooth and move for irreparable cuff tears (see this link)

The total shoulder arthroplasty (see this link).

The ream and run technique is shown in this link.

The cuff tear arthropathy arthroplasty (see this link).

The reverse total shoulder arthroplasty (see this link).

Shoulder rehabilitation exercises (see this link).

This is a non-commercial site, the purpose of which is education, consistent with "Fair Use" as defined in Title 17 of the U.S. Code.          

Note that author has no financial relationships with any orthopaedic companies.

Are antibiotic spacers a benign treatment for shoulder infections?

Complications of antibiotic cement spacers used for shoulder infections

These authors performed a retrospective review of one of two types of commercially available antibiotic spacers implanted in 53 patients (60 spacers) between April 2009 and October 2017 as part of a 2-stage treatment plan.

The 39 infected arthroplasties included 15 anatomic total shoulder arthroplasties, 13 hemiarthroplasties, 10 reverse total shoulder arthroplasties (RTSAs), and 1 cup arthroplasty. The nonarthroplasty shoulder infections included 4 after open reduction and internal fixation of proximal humeral fractures, 3 after rotator cuff repair, 1 after an infected Latarjet procedure, as well as 6 primary shoulder infections without previous surgical procedures. The 14 patients with non-arthroplasty infections had a septic joint with articular destruction and humeral head collapse that precluded any other joint-preservation treatment plan.

All patients were followed up from spacer placement to second-stage revision to shoulder arthroplasty. Ten patients retained the spacers and were followed up for a minimum of 1 year.

No complications were associated with implantation of the spacers. However, of the 44 patients (50 spacers) who underwent a second-stage revision after a mean interval of 6 months (range, 2-18 months), 14 patients had 18 complications.

Fourteen complications occurred between implantation and removal.  The most common complication was bone erosion (6 in the glenoid and 2 in the humeral shaft). 

Other complications were fractures of the spacer (n = 4), spacer rotation (n = 3), and humeral fracture (n = 3). 

 Comment: These authors state that the "infection" diagnosis was based on a combination of symptoms, clinical findings, and laboratory tests. For cases of periprosthetic infection, they used the Musculoskeletal Infection Society criteria (Clin Orthop Relat Res (2011) 469:2992–2994):

However, much of the information needed to use the MSIS criteria to classify a shoulder as being "infected" is not available at the time of the revision arthroplasty. Specifically the results of intraopertive cultures are not available in time to be used to determine the need for a spacer.  Thus, the indications for the use of a spacer are not well defined. 

This paper demonstrates that the use of spacers can be complicated by humeral and glenoid bone loss as well as by humeral and glenoid fracture. The authors also point out that achieving stability of the spacer in the canal can be challenging: insufficient fixation can lead to instability, while the use of cement for fixation can lead to difficulties in the removal of the spacer at the second stage. 

In most cases, our practice is to use a single stage revision without the intermediary of a spacer as our initial procedure in the management of a suspected periprosthetic infection (see this link). This procedure allows augmentation of the humeral bone stock and secure humeral component fixation using impaction allografting and minimizes glenoid erosion by using an implant with a smooth metallic surface rather than the more abrasive surface of a cement spacer. We reserve the use of spacers for failed single stage exchanges or when the presence of a particularly virulent organism (such as MRSA or gram negative rod) is suspected.

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