Safety of Administering Cefazolin in Beta-Lactam Allergic Patients Undergoing Elective Orthopaedic Procedures

Cefazolin is the preferred antibiotic for surgical site infection (SSI) prophylaxis in total joint arthroplasty due to its superior efficacy. However, patients labeled as allergic to beta-lactams often receive alternative antibiotics, increasing SSI risk. Despite historical concerns of cross-reactivity between penicillins and cephalosporins, recent data indicate a much lower risk, particularly for cefazolin.

This study evaluated the safety of a quality improvement protocol recommending cefazolin for SSI prophylaxis in patients labeled as beta-lactam allergic, excluding those who had documented cefazolin allergy. A retrospective review of 521 elective orthopaedic surgeries was conducted to identify hypersensitivity reactions (HSRs) following protocol implementation. Immediate HSRs were categorized as probable or possible based on perioperative clinical signs and responses to treatment.

Among the 521 patients, including 209 who had severe beta-lactam allergy histories, no probable HSRs were observed. There were 24 patients (5%) who experienced possible intraoperative HSRs, with 14 ruled out as cefazolin-related due to tolerance of subsequent doses. No patients required epinephrine or experienced severe hypersensitivity, and none were relabeled as cefazolin-allergic.

This study demonstrates the safety of cefazolin administration for SSI prophylaxis in beta-lactam-allergic patients, even those who had severe allergic histories. Previous studies corroborate the safety and efficacy of cefazolin compared to alternative antibiotics, supporting its use as the standard of care. The findings emphasize the safety of cefazolin for orthopaedic SSI prevention in beta-lactam-allergic patients, aligning with antimicrobial stewardship principles and reducing reliance on less effective alternatives.