Total shoulder arthroplasty: is Clindamycin a reasonable antibiotic in the penicillin allergic patient?

Perioperative Clindamycin Use in Penicillin Allergic Patients Is Associated With a Higher Risk of Infection After Shoulder Arthroplasty

These authors sought to determine whether infection rates differ between prophylactic antibiotic use for patients with or without penicillin allergy before shoulder arthroplasty surgery.

In 7140 primary shoulder arthroplasties operated between 2005 and 2016 they compared deep surgical site infection risk of patients who received perioperative vancomycin alone (6.2%,N= 444) or clindamycin alone (7.1%, N = 508) for penicillin allergy versus patients who received cefazolin alone without penicillin allergy (86.7%, N = 6,188).

Infections were identified using a comprehensive electronic screening algorithm of electronic medical records and administrative claims of the institution using International Classification of Disease, Clinical Modification, Ninth Revision (ICD-CM-9). They included all positive cultures with preoperative findings consistent with infection and negative cultures with positive surgeon findings for infection.The screening algorithm had a 97.8% sensitivity and 91.5% specificity.

Seventy deep infections (1.2% 5-year cumulative incidence) were observed. 

The most common organism was Cutibacterium (39.4%, N = 27). 

Compared with patients treated with cefazolin, infection risk was not different for those treated with vancomycin (hazard ratio = 1.17, 95% confidence interval 0.42 to 3.30, P = 0.8), but a higher risk of infection was identified for those treated with clindamycin alone (hazard ratio = 3.45, 95% confidence interval 1.84 to 6.47, P , 0.001).

They concluded that a four times higher risk of postoperative infection is found after prophylactic use of intravenous clindamycin antibiotic after shoulder arthroplasty and that Vancomycin is preferred over clindamycin for patients with penicillin allergy.

Comment: This important study gives us "news we can use" and demonstrates the great value of the Kaiser registry.

See related post What if my total shoulder patient says she's allergic to penicillin?

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