Antibiotic prophylaxis with alternative non-cefazolin protocol is not associated with higher rates of periprosthetic joint infection In total hip and total knee arthroplasty

Introduction: Prophylactic antibiotic administration of first or second-generation cephalosporins is standard of care for patients undergoing total joint arthroplasty (TJA). We evaluated the efficacy of a novel institution-specific non-cefazolin antibiotic protocol using vancomycin and aztreonam in preventing prosthetic joint infections (PJIs) for patients with allergies or intolerance. Methods: This single institution retrospective cohort study included patients undergoing primary TJA from 2018 to 2020 with two years of follow-up. The study cohort was divided into those who received cefazolin, cefazolin and vancomycin, vancomycin and aztreonam, and vancomycin alone as pre-operative antibiotic prophylaxis. Multi-variate logistic regression analyses were used to assess whether non-cefazolin antibiotics were associated with differences in the rates of acute PJIs, wound complications, reoperations, and readmissions after controlling demographics, comorbidities, type of TJA, and operative time. Results: Overall, 1,648 primary TJA encounters from 2018 to 2020 were included in the study, of which 109 patients (6.6%) received vancomycin and aztreonam. Significant differences existed between rates of postoperative transfusion, acute PJI, reoperation, and readmissions (P<0.001). Prophylaxis with vancomycin resulted in significantly higher rates of postoperative transfusion (P=0.003), acute PJI (P<0.001) and reoperations (P=0.004). However, no significant 90 day postoperative complication differences were appreciated between cefazolin and the vancomycin and aztreonam groups. Conclusion: Our institution specific prophylactic antibiotic protocol demonstrated similar efficacy to traditional cefazolin in patients undergoing TJA. Our findings further support prior literature highlighting increased risk for acute PJI and other postoperative complications in patients receiving vancomycin alone. Institutional standards should be evaluated against the traditional standard of care. Level of evidence: III