No difference in risk of revision due to infection between clindamycin and cephalosporins as antibiotic prophylaxis in cemented primary total knee replacements: a report from the Norwegian Arthroplasty Register 2005–2020
Keywords:Arthroplasty, Infection, Knee
Background and purpose: Systemic antibiotic prophylaxis with clindamycin, which is often used in penicillin- or cephalosporin-allergic patients’, has been associated with a higher risk of surgical revision for deep prosthetic joint infection (PJI) than cloxacillin in primary total knee replacement (TKR). We aimed to investigate whether clindamycin increases the risk of surgical revisions due to PJI compared with cephalosporins in primary cemented TKR.
Patients and methods: Data from 59,081 TKRs in the Norwegian Arthroplasty Register (NAR) 2005–2020 was included. 2,655 (5%) received clindamycin and 56,426 (95%) received cephalosporins. Cox regression analyses were performed with adjustment for sex, age groups, diagnosis, and ASA score. Survival times were calculated using Kaplan–Meier estimates and compared using Cox regression with revision for PJI as endpoint. The cephalosporins cefalotin and cefazolin were also compared.
Results: Of the TKRs included, 1.3% (n = 743) were revised for PJI. 96% (n = 713) had received cephalosporins and 4% (n = 30) clindamycin for perioperative prophylaxis. Comparing cephalosporins (reference) and clindamycin, at 3-month follow-up the adjusted hazard ratio rate (HRR) for PJI was 0.7 (95% confidence interval [CI] 0.4–1.4), at 1 year 0.9 (CI 0.6–1.5), and at 5 years 0.9 (CI 0.6–1.4). Analysis using propensity score matching showed similar results. Furthermore, comparing cefalotin (reference) and cefazolin, HRR was 1.0 (CI 0.8–1.4) at 3 months and 1.0 (CI 0.7–1.3) at 1-year follow-up.
Conclusion: We found no difference in risk of revision for PJI when using clindamycin compared with cephalosporins in primary cemented TKRs. It appears safe to continue the use of clindamycin in penicillin- or cephalosporin-allergic patients.
Dyrhovden G S, Lygre S H, Badawy M, Gøthesen Ø, Furnes O. Have the causes of revision for total and unicompartmental knee arthroplasties changed during the past two decades? Clin Orthop Relat Res 2017; 475(7): 1874-86. doi: 10.1007/s11999-017-5316-7. DOI: https://doi.org/10.1007/s11999-017-5316-7
Serrier H, Julien C, Batailler C, Mabrut E, Brochier C, Thevenon S, et al. Economic study of 2-stage exchange in patients with knee or hip prosthetic joint infection managed in a referral center in France: time to use innovative(s) intervention(s) at the time of reimplantation to reduce the risk of superinfection. Front Med 2021; 8: 552669. doi: 10.3389/fmed.2021.552669. DOI: https://doi.org/10.3389/fmed.2021.552669
Allegranzi B, Bischoff P, de Jonge S, Kubilay N Z, Zayed B, Gomes S M, et al. New WHO recommendations on preoperative measures for surgical site infection prevention: an evidence-based global perspective. Lancet Infect Dis 2016; 16(12): e276-e287. doi: 10.1016/S1473-3099(16)30398-X. DOI: https://doi.org/10.1016/S1473-3099(16)30398-X
Ortopedisk Kirurgi [Internet]. Helsedirektoratet [cited 2021 Jan 25]. Available from: https://www.helsedirektoratet.no/retningslinjer/antibiotika-i-sykehus/antibiotikaprofylakse-ved-kirurgi/ortopedisk-kirurgi#ortopedisk-kirurgi-med-leddprotese.
Robertsson O, Thompson O, W-Dahl A, Sundberg M, Lidgren L, Stefánsdóttir A. Higher risk of revision for infection using systemic clindamycin prophylaxis than with cloxacillin. Acta Orthop 2017; 88(5): 562-7. doi: 10.1080/17453674.2017.1324677. DOI: https://doi.org/10.1080/17453674.2017.1324677
Report 2022. Bergen: Norwegian Arthroplasty Register; 2022.
McNally M, Sousa R, Wouthuyzen-Bakker M, Chen A F, Soriano A, Vogely H C, et al. Infographic: The EBJIS definition of periprosthetic joint infection. Bone Joint J 2021; 103-B(1): 16-17. doi: 10.1302/0301-620X.103B1.BJJ-2020-2417. DOI: https://doi.org/10.1302/0301-620X.103B1.BJJ-2020-2417
Espehaug B, Furnes O, Havelin L I, Engesæter L B, Vollset S E, Kindseth O. Registration completeness in the Norwegian arthroplasty register. Acta Orthop 2006; 77(1): 49-56. doi: 10.1080/17453670610045696. DOI: https://doi.org/10.1080/17453670610045696
Badawy M, Espehaug B, Fenstad A M, Indrekvam K, Dale H, Havelin L I, et al. Patient and surgical factors affecting procedure duration and revision risk due to deep infection in primary total knee arthroplasty. BMC Musculoskelet Disord 2017; 18(1): 544. doi: 10.1186/s12891-017-1915-4. DOI: https://doi.org/10.1186/s12891-017-1915-4
Birkeland Ø, Espehaug B, Havelin L I, Furnes O. Bone cement product and failure in total knee arthroplasty. Acta Orthop 2016; 88(1): 75-81. Doi: 10.1080/17453674.2016.1256937. DOI: https://doi.org/10.1080/17453674.2016.1256937
Wyles C C, Hevesi M, Osmon D R, Park M A, Habermann E B, Lewallen D G, et al. John Charnley Award: Increased risk of prosthetic joint infection following primary total knee and hip arthroplasty with the use of alternative antibiotics to cefazolin. Bone Joint J 2019; 101-B(6_Supple_B): 9-15. doi: 10.1302/0301-620X.101B6.BJJ-2018-1407.R1. DOI: https://doi.org/10.1302/0301-620X.101B6.BJJ-2018-1407.R1
Leta T H, Gjertsen J-E, Dale H, Hallan G, Lygre S H, Fenstad A M, et al. Antibiotic-loaded bone cement in prevention of periprosthetic joint infections in primary total knee arthroplasty: a register-based multicentre randomized controlled non-inferiority trial (Alba Trial). BMJ Open 2021; 11(1): e041096. Doi: 10.1136/bmjopen-2020-041096. DOI: https://doi.org/10.1136/bmjopen-2020-041096
Dale H, Skråmm I, Løwer H L, Eriksen H M, Espehaug B, Furnes O, et al. Infection after primary hip arthroplasty. Acta Orthop 2011; 82(6): 646-54. doi: 10.3109/17453674.2011.636671. DOI: https://doi.org/10.3109/17453674.2011.636671
Van Kasteren M E, Mannien J, Ott A, Kullberg B-J, de Boer A S, Gyssens I C. Antibiotic prophylaxis and the risk of surgical site infections following total hip arthroplasty: timely administration is the most important factor. Clin Infect Dis 2007; 44(7): 921-7. doi: 10.1086/512192. DOI: https://doi.org/10.1086/512192
How to Cite
Copyright (c) 2023 Karola Pawloy, Anne Marie Fenstad, Tesfaye Leta, Geir Hallan, Jan-Erik Gjertsen, Håvard Dale, Stein Atle Lie, Ove Furnes
This work is licensed under a Creative Commons Attribution-NonCommercial 4.0 International License.