Documented Penicillin Allergies Should Not Preclude Use of Preoperative Cefazolin in Hip and Knee Arthroplasty

J Am Acad Orthop Surg. 2023 Jan 15;31(2):e107-e117. doi: 10.5435/JAAOS-D-22-00122.


Introduction: Perioperative cefazolin administration for total joint arthroplasty is a first-line antibiotic recommended by the American Academy of Orthopaedic Surgeons (AAOS) guidelines for the prevention of periprosthetic joint infections (PJIs). We aim to analyze the clinical viability of giving patients with a documented penicillin allergy (PA) a perioperative full-strength cefazolin "test dose" under anesthesia.

Methods: This is a retrospective chart review of 2,451 total joint arthroplasties from a high-volume arthroplasty orthopaedic surgeon over a 5-year period from January 2013 through December 2017. This surgeon routinely gave patients with a documented PA a full-strength cefazolin test dose while under anesthesia instead of administrating a second-line antibiotic. The primary outcomes examined were allergic reaction and postoperative infection.

Results: Cefazolin was given to 87.1% of all patients (1,990) and 46.0% of patients with a PA (143). The total rate of allergic reactions among all patients was 0.5% (11). Only one patient with a documented PA who received cefazolin had an allergic reaction. The reaction was not severe and did not require any additional treatment. In patients who had no reported allergies and received cefazolin, 0.3% (6) had an allergic reaction. There was no statistically significant difference in the rate of allergic reaction when comparing patients with and without a PA (P = 0.95). Patients receiving cefazolin had an overall PJI rate of 2.9% (57) versus those patients receiving antibiotics other than cefazolin who sustained a 5.5% PJI rate (16), which was statistically significant (P = 0.02).

Conclusion: This study found that utilization of a full-strength test dose of cefazolin in patients with a documented PA is a feasible, safe, and effective way of increasing the rate of cefazolin administration and thus mitigating the risk of PJIs.

MeSH terms

  • Anti-Bacterial Agents
  • Antibiotic Prophylaxis
  • Arthritis, Infectious* / etiology
  • Arthritis, Infectious* / prevention & control
  • Arthroplasty, Replacement, Hip* / adverse effects
  • Arthroplasty, Replacement, Knee* / adverse effects
  • Cefazolin
  • Drug Hypersensitivity* / etiology
  • Drug Hypersensitivity* / prevention & control
  • Humans
  • Hypersensitivity* / etiology
  • Penicillins / adverse effects
  • Prosthesis-Related Infections* / drug therapy
  • Prosthesis-Related Infections* / etiology
  • Prosthesis-Related Infections* / prevention & control
  • Retrospective Studies


  • Cefazolin
  • Anti-Bacterial Agents
  • Penicillins