Preoperative antibiotic prophylaxis in primary shoulder arthroplasty patients: a systematic review

Cefazolin is the primary antibiotic used for prevention of shoulder arthroplasty (SA) infection. However, vancomycin, clindamycin, and doxycycline may be used, specifically for patients with penicillin allergies or known bacterial colonization. Due to limited existing data, the aim of this systematic review was to characterize contemporary antibiotic prophylaxis choices and report infection rates based on the prophylactic regimen in patients undergoing SA.

The online databases CINAHL Complete, EMBASE, MEDLINE, the Cochrane Central Registry of Controlled Trials, and Web of Science were searched from database inception to September 25, 2024. Clinical studies comparing preoperative antibiotic regimens and reporting postoperative complications were included. Nonrandomized and randomized studies were assessed using the Methodological Index for Non-Randomized Studies tool and the revised Cochrane Risk of Bias 2 tool, respectively.

The search strategy identified 7 eligible studies, of which 2 were randomized controlled trials and 5 were retrospective series, including 33,159 procedures (hemiarthroplasty, anatomic total shoulder arthroplasty, reverse total shoulder arthroplasty, and humeral head arthroplasty). The most commonly used antibiotic was cefazolin. All-cause infection rates ranged from 1.0%-1.1% for cefazolin, 1.1%-2.4% for vancomycin, and 3.2%-4.1% for clindamycin. One randomized controlled trial found no significant reduction in intraoperative culture positivity rates with the addition of doxycycline to cefazolin.

Cefazolin is the preferred antibiotic prophylaxis for SA, with vancomycin and clindamycin as viable alternatives. Future investigations could evaluate the benefit of dual antibiotic therapy and develop evidence-based treatment algorithms for high-risk patients who may require non-cefazolin prophylaxis.