Increased Rates of Periprosthetic Joint Infection Following Hip Hemiarthroplasty with Clindamycin Prophylaxis Compared to Cefazolin

Overview

Journal Arch Orthop Trauma Surg

Specialties Emergency Medicine
General Surgery
Orthopedics

Date 2025 Feb 15

PMID 39954085

Authors

Nadav Graif

Nissan Amzallag

Assaf Kadar

Itay Ashkenazi

Shai Factor

Aviram Gold

Nimrod Snir

Yaniv Warschawski

Affiliations

Soon will be listed here.

Abstract

Purpose: To compare the efficacy of clindamycin versus cefazolin in preventing periprosthetic joint infection (PJI) in patients undergoing hip hemiarthroplasty (HA) for femoral neck fractures.

Methods: This retrospective cohort study included 1,139 patients aged ≥ 65 years who underwent HA for femoral neck fractures between January 2017 and October 2023. Patients received either Cefazolin + Gentamicin (n = 1001) or Clindamycin + Gentamicin (n = 138). Propensity score matching was performed at a 6:1 ratio, resulting in 828 patients in the cefazolin group and 138 in the clindamycin group. PJI rates, causative organisms, and mortality were compared. Multivariate logistic regression adjusted for potential confounders.

Results: The PJI rate was significantly higher in the clindamycin group compared to the cefazolin group (7.2% vs. 3.5%, p = 0.042). Multivariate analysis confirmed that clindamycin prophylaxis was independently associated with increased PJI risk (adjusted OR = 2.41, 95% CI: 1.16-4.99, p = 0.018). Other independent risk factors for PJI included age (adjusted OR = 1.03 per year, 95% CI: 1.01-1.05, p = 0.045), diabetes mellitus (adjusted OR = 1.76, 95% CI: 1.10-2.81, p = 0.018), and surgery duration (adjusted OR = 1.07 per minute, 95% CI: 1.01-1.16, p = 0.035). Staphylococcus aureus was the most common pathogen, with no significant differences in bacterial distribution between the groups. No significant differences were found in 30-day or 1-year mortality rates.

Conclusion: Clindamycin prophylaxis in hip hemiarthroplasty for femoral neck fractures is associated with a significantly higher risk of PJI compared to cefazolin. These findings support the preferential use of cefazolin in patients without contraindications and demonstrate the critical need for accurate assessment of reported beta-lactam allergies. Results suggest potential benefit from pre-operative allergy evaluation when feasible, as alternative prophylaxis choices may carry increased infection risk. Further research is needed to explore alternative prophylactic strategies for patients with beta-lactam allergies.

References

Gjertsen J, Fenstad A, Leonardsson O, Engesaeter L, Karrholm J, Furnes O . Hemiarthroplasties after hip fractures in Norway and Sweden: a collaboration between the Norwegian and Swedish national registries. Hip Int. 2014; 24(3):223-30. PMC: 6159838. DOI: 10.5301/hipint.5000105. View

de Haan E, Roukema G, van Rijckevorsel V, Kuijper T, de Jong L . Risk factors for prosthetic joint infections after hemiarthroplasty of the hip following a femoral neck fracture. Injury. 2023; 55(2):111195. DOI: 10.1016/j.injury.2023.111195. View

Guren E, Figved W, Frihagen F, Watne L, Westberg M . Prosthetic joint infection-a devastating complication of hemiarthroplasty for hip fracture. Acta Orthop. 2017; 88(4):383-389. PMC: 5499328. DOI: 10.1080/17453674.2017.1301009. View

Del Toro M, Nieto I, Guerrero F, Corzo J, Del Arco A, Palomino J . Are hip hemiarthroplasty and total hip arthroplasty infections different entities? The importance of hip fractures. Eur J Clin Microbiol Infect Dis. 2014; 33(8):1439-48. DOI: 10.1007/s10096-014-2091-1. View

Rodriguez-Pardo D, Escola-Verge L, Sellares-Nadal J, Corona P, Almirante B, Pigrau C . Periprosthetic Joint Infection Prophylaxis in the Elderly after Hip Hemiarthroplasty in Proximal Femur Fractures: Insights and Challenges. Antibiotics (Basel). 2021; 10(4). PMC: 8069667. DOI: 10.3390/antibiotics10040429. View

Parvizi J, Azzam K, Ghanem E, Austin M, Rothman R . Periprosthetic infection due to resistant staphylococci: serious problems on the horizon. Clin Orthop Relat Res. 2009; 467(7):1732-9. PMC: 2690767. DOI: 10.1007/s11999-009-0857-z. View

Tornero E, Garcia-Ramiro S, Martinez-Pastor J, Bori G, Bosch J, Morata L . Prophylaxis with teicoplanin and cefuroxime reduces the rate of prosthetic joint infection after primary arthroplasty. Antimicrob Agents Chemother. 2014; 59(2):831-7. PMC: 4335835. DOI: 10.1128/AAC.03949-14. View

Krasin E, Warschawski Y, Morgan S, Dekel M . Antibiotic prophylaxis in orthopedic surgery; has the time to reconsider the current practice arrived?. J Orthop. 2022; 32:68-71. PMC: 9117254. DOI: 10.1016/j.jor.2022.05.008. View

Amzallag N, Ashkenazi I, Factor S, Abadi M, Morgan S, Graif N . Addition of gentamicin for antibiotic prophylaxis in hip hemiarthroplasty does not decrease the rate of surgical site infection. Eur J Trauma Emerg Surg. 2023; 50(3):867-873. DOI: 10.1007/s00068-023-02406-6. View

10.

Ashkenazi I, Amzallag N, Snir N, Morgan S, Garceau S, Kotz L . Does addition of gentamicin for antibiotic prophylaxis in total knee arthroplasty reduce the rate of periprosthetic joint infection?. Arch Orthop Trauma Surg. 2022; 143(8):5255-5260. DOI: 10.1007/s00402-022-04744-3. View

11.

Peel T, Cheng A, Buising K, Choong P . Microbiological aetiology, epidemiology, and clinical profile of prosthetic joint infections: are current antibiotic prophylaxis guidelines effective?. Antimicrob Agents Chemother. 2012; 56(5):2386-91. PMC: 3346661. DOI: 10.1128/AAC.06246-11. View

12.

Branch-Elliman W, OBrien W, Strymish J, Itani K, Wyatt C, Gupta K . Association of Duration and Type of Surgical Prophylaxis With Antimicrobial-Associated Adverse Events. JAMA Surg. 2019; 154(7):590-598. PMC: 6487902. DOI: 10.1001/jamasurg.2019.0569. View

13.

Kheir M, Tan T, Azboy I, Tan D, Parvizi J . Vancomycin Prophylaxis for Total Joint Arthroplasty: Incorrectly Dosed and Has a Higher Rate of Periprosthetic Infection Than Cefazolin. Clin Orthop Relat Res. 2017; 475(7):1767-1774. PMC: 5449331. DOI: 10.1007/s11999-017-5302-0. View

14.

Kazley J, Banerjee S, Abousayed M, Rosenbaum A . Classifications in Brief: Garden Classification of Femoral Neck Fractures. Clin Orthop Relat Res. 2018; 476(2):441-445. PMC: 6259691. DOI: 10.1007/s11999.0000000000000066. View

15.

Parvizi J, Zmistowski B, Berbari E, Bauer T, Springer B, Della Valle C . New definition for periprosthetic joint infection: from the Workgroup of the Musculoskeletal Infection Society. Clin Orthop Relat Res. 2011; 469(11):2992-4. PMC: 3183178. DOI: 10.1007/s11999-011-2102-9. View

16.

Tan T, Springer B, Ruder J, Ruffolo M, Chen A . Is Vancomycin-only Prophylaxis for Patients With Penicillin Allergy Associated With Increased Risk of Infection After Arthroplasty?. Clin Orthop Relat Res. 2015; 474(7):1601-6. PMC: 4887347. DOI: 10.1007/s11999-015-4672-4. View

17.

Tan T, Shohat N, Rondon A, Foltz C, Goswami K, Ryan S . Perioperative Antibiotic Prophylaxis in Total Joint Arthroplasty: A Single Dose Is as Effective as Multiple Doses. J Bone Joint Surg Am. 2019; 101(5):429-437. DOI: 10.2106/JBJS.18.00336. View

18.

Kunutsor S, Whitehouse M, Blom A, Beswick A . Patient-Related Risk Factors for Periprosthetic Joint Infection after Total Joint Arthroplasty: A Systematic Review and Meta-Analysis. PLoS One. 2016; 11(3):e0150866. PMC: 4777569. DOI: 10.1371/journal.pone.0150866. View

19.

Bzovsky S, Comeau-Gauthier M, Schemitsch E, Swiontkowski M, Heels-Ansdell D, Frihagen F . Factors Associated With Mortality After Surgical Management of Femoral Neck Fractures. J Orthop Trauma. 2020; 34 Suppl 3:S15-S21. DOI: 10.1097/BOT.0000000000001937. View

20.

Saeed K, Dryden M, Bassetti M, Bonnet E, Bouza E, Chan M . Prosthetic joints: shining lights on challenging blind spots. Int J Antimicrob Agents. 2016; 49(2):153-161. DOI: 10.1016/j.ijantimicag.2016.10.015. View