Is the shoulder an indication for prophylactic (preventive) antibiotics?

From the Guidelines

Prophylactic antibiotics are not routinely recommended for most shoulder procedures, but are indicated for open shoulder surgeries, shoulder arthroplasty, or in high-risk patients. For standard arthroscopic shoulder surgeries in patients without risk factors, antibiotics are generally unnecessary as infection rates are already very low (less than 1%) 1. However, for open shoulder surgeries, shoulder arthroplasty (replacement), or in high-risk patients, prophylactic antibiotics are recommended. When indicated, a first-generation cephalosporin like cefazolin (1-2g IV) given within 60 minutes before incision is the standard regimen 1. For patients with beta-lactam allergies, clindamycin (600-900mg IV) or vancomycin (15mg/kg IV) can be used. The antibiotic should be discontinued within 24 hours after surgery in most cases. High-risk patients who benefit from prophylaxis include those with immunosuppression, diabetes, rheumatoid arthritis, previous shoulder surgery, or implantation of prosthetic materials. The rationale for selective antibiotic use balances infection prevention against potential adverse effects like allergic reactions, antibiotic resistance, and Clostridioides difficile infections. The most common shoulder infection pathogens are skin flora, particularly Staphylococcus species, which these antibiotic choices effectively target.

Key Considerations

• Antibiotic prophylaxis should be administered for operative procedures that have a high rate of postoperative surgical site infection, or when foreign materials are implanted 1.
• Antibiotic prophylaxis should be administered within 120 min prior to the incision, with administration of the first dose of antibiotics beginning within 30–60 min before the surgical incision recommended for most antibiotics 1.
• A single dose is generally sufficient, with additional antibiotic doses administered intraoperatively for procedures > 2–4 h or with associated significant blood loss 1.
• There is no evidence to support the use of postoperative antibiotic prophylaxis 1.

High-Risk Patients

• Patients with immunosuppression, diabetes, rheumatoid arthritis, previous shoulder surgery, or implantation of prosthetic materials are considered high-risk and may benefit from prophylactic antibiotics.
• These patients should be carefully evaluated on a case-by-case basis to determine the need for antibiotic prophylaxis.

From the Research

Shoulder Indication for Prophylactic Antibiotics

• The use of prophylactic antibiotics in shoulder arthroplasty is a common practice to prevent surgical site infections (SSIs) and periprosthetic joint infections (PJIs) 2, 3, 4, 5, 6.
• Cefazolin is the most commonly used antibiotic for prophylaxis in shoulder arthroplasty, and its effectiveness has been compared to other antibiotics such as vancomycin and clindamycin 2, 3, 6.
• Studies have shown that cefazolin is associated with lower rates of PJI and SSI compared to non-cefazolin alternatives, including vancomycin and clindamycin 6.
• Vancomycin is often used as an alternative to cefazolin in patients with a penicillin allergy, but its effectiveness in preventing PJI and SSI is still debated 2, 3, 5.
• Clindamycin is also used as an alternative to cefazolin, but it has been associated with a higher risk of PJI and SSI compared to cefazolin 3, 6.

Comparative Effectiveness of Prophylactic Antibiotics

• A study published in the Journal of Shoulder and Elbow Surgery found that complete vancomycin administration did not increase the rates of infectious complications compared to cefazolin administration in primary shoulder arthroplasty 2.
• Another study published in the Journal of the American Academy of Orthopaedic Surgeons found that vancomycin was preferred over clindamycin for patients with a penicillin allergy, as clindamycin was associated with a higher risk of infection 3.
• A multicenter, double-blind, superiority, placebo-controlled trial published in the New England Journal of Medicine found that the addition of vancomycin to cefazolin prophylaxis did not reduce surgical-site infections in arthroplasty among patients without known MRSA colonization 4.
• A retrospective cohort study published in the Journal of Bone and Joint Surgery found that cefazolin was associated with lower shoulder periprosthetic joint infection rates than non-cefazolin alternatives, including vancomycin and clindamycin 6.

Recommendations for Prophylactic Antibiotics

• The choice of prophylactic antibiotic should be based on the patient's allergy history and the surgeon's preference 2, 3, 6.
• Cefazolin is recommended as the first-line antibiotic for prophylaxis in shoulder arthroplasty, unless the patient has a penicillin allergy 6.
• Vancomycin may be used as an alternative to cefazolin in patients with a penicillin allergy, but its effectiveness in preventing PJI and SSI should be carefully considered 2, 3, 5.
• Clindamycin should be used with caution, as it has been associated with a higher risk of PJI and SSI compared to cefazolin 3, 6.