98. Antibiotic Stewardship Interventions Significantly Improve Preferred Antibiotic Prophylaxis in Total Joint Arthroplasty

BACKGROUND: Most patients reporting a penicillin (PCN) allergy can tolerate cefazolin, the preferred prophylaxis in a total joint arthroplasty (TJA). The purpose of this study was to evaluate surgical prophylaxis in patients with a reported PCN allergy undergoing a TJA following a stewardship intervention that included updates to institutional guidelines, reclassification of severe PCN allergy, standardization of ordering processes, and participation of a physician champion. METHODS: This was a single center, retrospective study of adult orthopedic patients greater than 18 years old who underwent a primary elective TJA at a 261-bed community hospital from March 1, 2017 to August 30, 2017 (pre-intervention) and from March 1, 2019 to August 30, 2019 (post-intervention). The primary outcome was the difference in the composite rate of the following: 1) Patients with a reported non-severe PCN allergy without MRSA risk factors who received cefazolin; 2) Patients with a non-severe PCN allergy with MRSA risks factors who received cefazolin plus vancomycin; and 3) Patients with a severe PCN allergy who received vancomycin prior to a primary elective TJA. RESULTS: A total of 180 patients with a documented PCN allergy were evaluated (90 patients in the pre-intervention group and 90 patients in the post-intervention group). Rash and hives were the most commonly reported allergies in both groups (71% vs 61%, P=0.2076). Post-intervention revealed a significant increase in the primary outcome of appropriate perioperative antibiotic (55% vs 91%, P< 0.001), largely driven by patients with non-severe allergy [47% (36/76) vs 96% (73/76), P< 0.001]. No patients had signs of an allergic reaction thought to be due to cefazolin, including 8 patients with severe PCN allergy. No patients in either group developed a surgical site infection or C. difficile infection within 90 days post-procedure. CONCLUSION: A multifaceted antibiotic stewardship intervention increased preferred prophylaxis in elective primary TJA. Patients with non-severe PCN allergies, even those reporting hives or local swelling, can tolerate cefazolin without issue. Patients with severe PCN allergy should undergo further evaluation as cefazolin may be a safe option. DISCLOSURES: Katelyn Quartuccio, PharmD, BCPS, AstraZeneca (Consultant) Kelly E. Pillinger, PharmD, BCIDP, Pharmacy Times (Other Financial or Material Support, Speaker)