Preoperative Allergy Testing for Patients Reporting Penicillin and Cephalosporin Allergies is Cost-Effective in Preventing Infection after Total Knee and Hip Arthroplasty

J Arthroplasty. 2021 Feb;36(2):700-704. doi: 10.1016/j.arth.2020.08.045. Epub 2020 Aug 27.


Background: Routine preoperative allergy testing in patients reporting penicillin and cephalosporin allergies increases the number able to receive cefazolin, which should reduce the risk of infection after total knee and hip arthroplasty (TKA/THA), but it remains unclear whether this practice is cost-effective. Using a break-even analysis, we calculated the cost-effectiveness of routine preoperative allergy testing for infection prevention in total joint arthroplasty patients reporting penicillin and cephalosporin allergies.

Methods: The cost of a penicillin allergy evaluation, the cost of revision arthroplasty for prosthetic joint infection (PJI), and baseline rates of PJI in patients receiving a noncefazolin antibiotic in the perioperative period were derived from existing literature. A break-even economic model using these variables was constructed to calculate the absolute risk reduction (ARR) in infection rate needed for preoperative allergy testing to be cost-effective. The number needed to treat (NNT) was calculated from the ARR.

Results: Preoperative allergy testing before TKA and THA in patients reporting penicillin and cephalosporin allergies was cost-effective if the initial infection rate decreased by an ARR of 0.810% (NNT = 123) and 0.655% (NNT = 153) for TKA and THA, respectively. Cost-effectiveness was maintained with varying allergy consultation costs, infection rates, and costs associated with PJI treatment.

Conclusion: Routine preoperative allergy testing and clearance are cost-effective infection prevention strategies among patients reporting penicillin and cephalosporin allergies in the setting of elective joint arthroplasty. Widespread adoption of this practice may considerably reduce the economic and societal burden associated with prosthetic infections.

Keywords: allergy testing; antibiotic prophylaxis; cefazolin; cost; prosthetic joint infection; total joint arthroplasty.

MeSH terms

  • Anti-Bacterial Agents / adverse effects
  • Arthroplasty, Replacement, Hip* / adverse effects
  • Arthroplasty, Replacement, Knee* / adverse effects
  • Cefazolin
  • Cost-Benefit Analysis
  • Humans
  • Penicillins / adverse effects
  • Prosthesis-Related Infections* / drug therapy
  • Retrospective Studies


  • Anti-Bacterial Agents
  • Penicillins
  • Cefazolin