JOA - 2026-09-21 - Journal Article
Increased Risk of Periprosthetic Joint Infection Following Aseptic Revision Hip and Knee Arthroplasty With the Use of Non-Cefazolin Alternative Antibiotics.
Panos JA, Mallinger BD, Virk A, Sierra RJ, Abdel MP, Wyles CC
Topics
Key Takeaway
Perioperative cefazolin prophylaxis reduces PJI risk by 50% (HR 0.5) compared to non-cefazolin alternatives in aseptic revision TKA and THA.
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Summary
This single-institution retrospective cohort examined PJI incidence in aseptic revision TJA stratified by perioperative antibiotic type, postoperative oral antibiotic regimen, and unexpected positive culture (UPC) status using Cox proportional hazards regression. Of 5,993 revisions, 4% developed PJI; cefazolin prophylaxis (used in 94% of cases) conferred significantly higher PJI-free survivorship versus non-cefazolin alternatives (HR 0.5, p=0.006). Addition of oral cephalosporins (cefadroxil or cephalexin) to cefazolin did not reduce PJI risk, and UPCs (4% incidence, 44% coagulase-negative Staphylococcus) were not significantly associated with subsequent PJI (HR 1.5, p=0.21).
Key Limitation
The non-cefazolin group (6% of cohort) is too small and likely systematically different (true penicillin allergy, MRSA colonization, higher comorbidity) to permit valid causal inference from the HR 0.5 estimate.
Original Abstract
BACKGROUND
Although perioperative cefazolin antibiotic prophylaxis is associated with a reduced risk of periprosthetic joint infection (PJI) in primary total joint arthroplasty (TJA) compared to non-cefazolin alternatives, its relative efficacy in the aseptic revision setting is less defined. Furthermore, the roles of postoperative oral antibiotic prophylaxis and the management of unexpected positive cultures (UPC) remain controversial. Therefore, we examined PJI in aseptic revision TJA based on (1) perioperative antibiotic prophylaxis, (2) postoperative oral antibiotic regimen, and (3) UPC status.
METHODS
We evaluated all patients undergoing aseptic revision total knee arthroplasty (TKA) and total hip arthroplasty (THA) at a single academic institution between January 2000 and March 2024, yielding 5,993 revision arthroplasties (n = 3,429 THA, n = 2,564 TKA). Cases were analyzed based on perioperative antibiotic type (cefazolin versus non-cefazolin), postoperative oral antibiotic regimen, and intraoperative culture results. Cox proportional hazards regressions were used to determine survivorship free from PJI.
RESULTS
Among this cohort, 94% received cefazolin perioperative prophylaxis. In total, 234 cases (4%) subsequently developed PJI. Cefazolin perioperative prophylaxis was associated with significantly higher survivorship free from PJI compared to non-cefazolin alternatives (hazard ratio (HR): 0.5; P = 0.006). In patients receiving perioperative cefazolin, the addition of oral antibiotics with either cefadroxil or cephalexin did not significantly reduce PJI risk compared to no oral antibiotics. The incidence of UPCs was 4%, most commonly coagulase-negative Staphylococcus (44%), and was not significantly associated with subsequent PJI (HR: 1.5; P = 0.21).
CONCLUSION
Perioperative cefazolin prophylaxis is a critical modifiable risk factor, providing a substantial protective effect against PJI in aseptic revision TJA. In contrast, extended oral antibiotic prophylaxis provided no additional benefit for culture-negative patients. While UPCs occurred in 4% of cases, only one case subsequently developed PJI with a concordant microorganism. These findings reinforce the importance of standardized cefazolin prophylaxis over alternative agents in aseptic revision TJA.