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).

When is it safe to give cephalosporin antibiotic prophylaxis to patients who are "allergic to penicillin"?

A Simple Algorithmic Approach Allows the Safe Use of Cephalosporin in “Penicillin-Allergic” Patients without the Need for Allergy Testing

These authors assessed the effectiveness of a simple, protocol-driven penicillin allergy screening program to predict the safety of administering cephalosporins to patients with a history of allergic reaction to penicillin.

Patients scheduled having primary total joint arthroplasty were risk-stratified into low or high-risk categories based on the criteria below:

The low-risk cohort received cefazolin, and the high-risk cohort received non-cefazolin antibiotics. 

The study group (n = 2,078) was propensity score matched 1:1 with a control group that included patients who underwent TJA in the same institution prior to implementation of the protocol. 

A total of 357 patients (17.2%) reported a penicillin allergy in the study group compared with 310 patients (14.9%) with a recorded allergy in the control group. 

The allergy history of the patients in the study group is shown below

The number of patients who received non-cephalosporin antibiotics was significantly lower in the study group (5.7% compared with 15.2% in the control group).

There was no difference in the rate of total allergic reactions (0.8% compared with 0.7%.

Of the 239 low-risk patients (66.9%) in the study group, only 3 (1.3%) experienced a mild cutaneous reaction following cefazolin administration. 

There were no differences in the rates of superficial wound, deep periprosthetic, or Clostridioides difficile infections between the protocol and control groups.

Thus the screening protocol allowed two-thirds of patients with a self-reported allergy to receive cefazolin without the need for additional consultations or testing; the overall rate of cefazolin usage

increased by 9%, to 94%, without an increase in adverse reactions.

The authors' protocol includes amending the medical record to indicate safe administration of cephalosporin as shown below

Comment: These data are of great importance to shoulder arthroplasty surgeons and their patients. Cutibacterium is the organism that causes most shoulder periprosthetic infections. Cephalosporins appear to be the antibiotic most effective against Cutibacterium. While Clindamycin is often used as prophylaxis in patients thought to be allergic to penicillin, over 25% of Cutibacterium have been found to be resistant to Clindamycin (see this link). 

As the authors point out, when tolerance of cephalosporins is observed, it is important to amend the medical record to so indicate. 

Another particularly informative article on this subject is Evaluation and Management of Penicillin Allergy A Review The abstract is reproduced below:

IMPORTANCE β-Lactam antibiotics are among the safest and most effective antibiotics. Many patients report allergies to these drugs that limit their use, resulting in the use of broad-spectrum antibiotics that increase the risk for antimicrobial resistance and adverse events.

OBSERVATIONS Approximately 10% of the US population has reported allergies to the β-lactam agent penicillin, with higher rates reported by older and hospitalized patients. Although many patients report that they are allergic to penicillin, clinically significant IgE-mediated or T lymphocyte–mediated penicillin hypersensitivity is uncommon (<5%). Currently, the rate of IgE-mediated penicillin allergies is decreasing, potentially due to a decreased use of parenteral penicillins, and because severe anaphylactic reactions to oral amoxicillin are rare. IgE-mediated penicillin allergy wanes over time, with 80% of patients becoming tolerant after a decade. Cross-reactivity between penicillin and cephalosporin drugs occurs in about 2%of cases, less than the 8%reported previously. Some patients have a medical history that suggests they are at a low risk for developing an allergic reaction to penicillin. Low-risk histories include patients having isolated nonallergic symptoms, such as gastrointestinal symptoms, or patients solely with a family history of a penicillin allergy, symptoms of pruritus without rash, or remote (>10 years) unknown reactions without features suggestive of an IgE-mediated reaction. A moderate-risk history includes urticaria or other pruritic rashes and reactions with features of IgE-mediated reactions. A high-risk history includes patients who have had anaphylaxis, positive penicillin skin testing, recurrent penicillin reactions, or hypersensitivities to multiple β-lactam antibiotics. The goals of antimicrobial stewardship are undermined when reported allergy to penicillin leads to the use of broad-spectrum antibiotics that increase the risk for antimicrobial resistance, including increased risk of methicillin-resistant Staphylococcus aureus and vancomycin-resistant Enterococcus. Broad-spectrum antimicrobial agents also increase the risk of developing Clostridium difficile (also known as Clostridioides difficile) infection. Direct amoxicillin challenge is appropriate for patients with low-risk allergy histories. Moderate-risk patients can be evaluated with penicillin skin testing, which carries a negative predictive value that exceeds 95%and approaches 100% when combined with amoxicillin challenge. Clinicians performing penicillin allergy evaluation need to identify what methods are supported by their available resources.

CONCLUSIONS AND RELEVANCE Many patients report they are allergic to penicillin but few have clinically significant reactions. Evaluation of penicillin allergy before deciding not to use penicillin or other β-lactam antibiotics is an important tool for antimicrobial stewardship.

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

 

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?

Our approach to total shoulder arthroplasty can be viewed by clicking here.

To see our technique for reverse total shoulder, click on this link.

To support our research to improve outcomes for patients with shoulder problems, click here.

To subscribe to this blog, enter your email in the box to your right that looks like the below

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

We have a new set of shoulder youtubes about the shoulder, check them out at this link.

Be sure to visit "Ream and Run - the state of the art" regarding this radically conservative approach to shoulder arthritis at this link and this link

Use the "Search" box to the right to find other topics of interest to you.

You may be interested in some of our most visited web pages  arthritis, total shoulder, ream and run, reverse total shoulder, CTA arthroplasty, and rotator cuff surgery as well as the 'ream and run essentials'

What if my total shoulder patient says she is allergic to penicillin?

Is Patient-reported Penicillin Allergy Independently Associated with Increased Risk of Prosthetic Joint Infection After Total Joint Arthroplasty of the Hip, Knee, and Shoulder?

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).

Our approach to total shoulder arthroplasty can be viewed by clicking here.

To see our technique for reverse total shoulder, click on this link.

To support our research to improve outcomes for patients with shoulder problems, click here.

To subscribe to this blog, enter your email in the box to your right that looks like the below

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

We have a new set of shoulder youtubes about the shoulder, check them out at this link.

Be sure to visit "Ream and Run - the state of the art" regarding this radically conservative approach to shoulder arthritis at this link and this link

Use the "Search" box to the right to find other topics of interest to you.

You may be interested in some of our most visited web pages  arthritis, total shoulder, ream and run, reverse total shoulder, CTA arthroplasty, and rotator cuff surgery as well as the 'ream and run essentials'