These authors note that patients with a self-reported penicillin allergy may be at greater risk for postoperative prosthetic joint infection (PJI) after total joint arthroplasty of the hip, knee, or shoulder. This increased risk of PJI has been attributed to these patients receiving a less-effective perioperative antibiotic.
They asked, "are patients with a patient-reported penicillin allergy more likely to have a PJI after THA, TKA, or total shoulder arthroplasty than patients without such a reported allergy after controlling for risk factors such as BMI, anxiety, depression, and other comorbidities?"
They queried the records of 122 million patients comparing the 1-year incidence of PJI after TKA, total shoulder arthroplasty, and THA in patients with patient-reported penicillin allergy versus patients without a patient-reported penicillin allergy.
After adjusting for potential confounding factors such as BMI, anxiety, depression and other comorbidities, they found that patient-reported penicillin allergy was independently associated with an increased odds of PJI after total shoulder arthroplasty (OR 3.9 [95% CI 2.7 to 5.4]; p < 0.01).
The authors suspected but did not prove that this finding is a result of those patients reporting penicillin allergy receiving a second-line antibiotic for presurgical prophylaxis. Recent studies have demonstrated that 76%to 93% of patients with a patient-reported penicillin allergy receive noncephalosporin antibiotics such as clindamycin. Patients with a patient-reported pencillin allergy receiving clindamycin alone before total shoulder arthroplasty had a greater infection risk than did patients who received cefazolin alone (hazard ratio = 3.45) (see this link).
Of note is the fact that Cutibacterium, the most common cause of shoulder PJI, has variable susceptibility to the second-line antibiotics commonly used in patients with a patient-reported penicillin allergy (see link, link, link_A multi-institutional study of patients undergoing total shoulder arthroplasty demonstrated that patients with penicillin allergy receiving perioperative intravenous clindamycin had a four-times higher risk of a Cutibacterium infection compared with those receiving cefazolin (see link).
These authors suggest that in light of the observation that many patients reporting a penicillin allergy are in fact not allergic to penicillin, they suggest that surgeons consider preoperative allergy testing, such as using an intraoperative test dose, to aid in choosing the most appropriate antibiotic choice prior to shoulder arthroplasty and to amend patient medical records based on testing results. Similar to a skin test, the likelihood of anaphylaxis is low with the intraoperative test dose given the low probability of a true cephalopsorin allergy. Advantages of the intraoperative test dose are that reagents are easier to acquire than the skin test, and that the test can be performed in the relative safety of the anesthetic suite or operating room in case of adverse events.
Another factor to consider is that patients who are truly allergic to penicillin may have altered host defenses making them more susceptible to infection. It has been noted that patient allergies may be associated with inferior outcomes from shoulder arthroplasty (see link).
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