Survey Results Reveal Providers’ Misconceptions About Penicillin Allergies and Cefazolin Use in Arthroplasty Patients

Prosthetic joint infection (PJI) is a devastating complication following total joint arthroplasty (TJA). Cefazolin is the preferred perioperative antibiotic compared to alternatives, such as clindamycin or vancomycin. Concern for cross-reactivity with penicillin often leads providers to avoid cefazolin in penicillin-allergic patients, despite studies showing that patients with severe penicillin allergies tolerate cefazolin. We hypothesized that providers avoid using cefazolin in penicillin-allergic TJA patients due to misconceptions regarding cross-reactivity and perceived efficacy of alternative agents. A 22-question survey was distributed to the orthopaedic surgery, anesthesiology, and CRNA departments of 6 academic hospitals, 2 community hospitals, and 1 orthopaedic private practice and was open for 2 months. Response patterns were analyzed across groups. Many providers stated they would use an alternative antibiotic for a total hip arthroplasty (THA) patient with an unspecified penicillin allergy (5.9% anesthesiology, 14.7% CRNA, 11.6% orthopaedics) and total knee arthroplasty (TKA) (5.9%, 17.6%, and 9.3%, respectively). For an anaphylactic penicillin allergy, more providers used alternative agents for THA (47.1%, 58.8%, and 58.1%, respectively) and TKA (51%, 58.8%, and 60.4%, respectively). When asked if alternative antibiotics are as effective as cefazolin for TJA patients, 37.3% anesthesiology, 61.8% CRNA, and 41.9% orthopaedics answered “Yes.” Many providers incorrectly answered the rate of self-reported penicillin allergies (58.8% anesthesiology, 67.6% CRNA, 62.3% orthopaedics) and the cross-reactivity of penicillin and cefazolin (27.5%, 35.3%, 39.5%, respectively). Prevalent avoidance of cefazolin in penicillin-allergic patients and substantial rates of incorrect responses highlight the need for education on current recommendations for TJA perioperative antibiotics.