Does prophylactic antibiotic choice for total shoulder arthroplasty matter? A matched cohort analysis

Periprosthetic joint infection (PJI) of the shoulder is a devastating complication following total shoulder arthroplasty (TSA). The majority of literature regarding antibiotic choice for TSA is from accompanying literature in other orthopedic subspecialties. The purpose of this study was to delineate the relationship between various perioperative antibiotics, including local, topical vancomycin, and their potential protective effect on PJI following shoulder arthroplasty.

A retrospective cohort study was conducted using the TriNetX database to identify 28,098 patients who underwent TSA. Patients were stratified into cohorts based on the type of prophylactic antibiotic received in the perioperative period-only cefazolin, noncefazolin prophylaxis, vancomycin only, cefazolin with any form of vancomycin, cefazolin with topical vancomycin, only clindamycin, and cefazolin with clindamycin. The later 6 cohorts were one-to-one propensity score matched with the cefazolin-only cohort for risk analysis. The 90-day and 2-year risk of PJI and revision was analyzed, in addition to other surgical, hospital readmission, or emergency department visit complications.

At 2 years, cefazolin monotherapy was associated with a significantly lower incidence of prosthetic joint infection and overall infection than noncefazolin regimens. No significant differences were found when cefazolin was compared with vancomycin alone or clindamycin alone. Adding local vancomycin did not significantly reduce the risk of PJI at any time point. Secondary antibiotic prophylaxis in addition to cefazolin was not associated with a decreased risk of infection at any time point.

Antibiotic prophylaxis choice for TSA may vary based on the surgeon's preference. Noncefazolin prophylaxis may not provide the same protection against PJI and overall infection as cefazolin prophylaxis. Cefazolin monotherapy is associated with lower infection rates compared to other noncefazolin regimens, suggesting that cefazolin should be used preferentially. However, prospective trials are required to further elucidate this finding.