Comparison of ceftriaxone and cefazolin as prophylactic antibiotics for surgical site infection in orthopedic upper extremity surgery: The nationwide shortage of cefazolin in March 2019

Published:September 08, 2022DOI:



      Due to the nationwide supply shortage of cefazolin in March 2019 in Japan, ceftriaxone was used as an alternative prophylaxis antibiotic agent. This retrospective study was designed to investigate the impact of cefazolin and ceftriaxone as a prophylactic antibiotic agent for surgical site infection (SSI) in orthopedic upper extremity surgery.


      We used cefazolin for antibiotic prophylaxis to prevent SSI before March 2019. Because of cefazolin shortage, ceftriaxone was used as an alternative agent in our hospital. From April 2014 to May 2021, 2493 upper extremity surgeries were reviewed. The exclusion criteria in this study were as follows: patients aged under 16 years, those with an open wound, those with infectious diseases, those who underwent trigger finger surgery, and those who underwent percutaneous pinning surgery. The incidence of deep SSI was evaluated according to the Centers for Disease Control and Prevention guidelines.


      Among the 2493 eligible cases, 1674 were included in this study. In the cefazolin group, 1140 cases were included, whereas, in the ceftriaxone group, 534 cases were included. No significant differences in the demographic data of the patients were observed between the two groups. The incidence of deep SSI was 0.08% (1/1140 cases) in the cefazolin group and 1.1% (6/534 cases) in the ceftriaxone group, with a significant difference between the two groups (odds ratio, 12.9; p = 0.005).


      This study indicated that the use of ceftriaxone instead of cefazolin after upper extremity surgery increases the risk of deep SSI.


      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      Subscribe to Journal of Orthopaedic Science
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • Whitehouse J.D.
        • Friedman N.D.
        • Kirkland K.B.
        • Richardson W.J.
        • Sexton D.J.
        The impact of surgical-site infections following orthopedic surgery at a community hospital and a university hospital: adverse quality of life, excess length of stay, and extra cost.
        Infect Control Hosp Epidemiol. 2002 Apr; 23: 183-189
        • Bratzler D.W.
        • Dellinger E.P.
        • Olsen K.M.
        • Perl T.M.
        • Auwaerter P.G.
        • Bolon M.K.
        • et al.
        American Society of Health-System Pharmacists (ASHP), infectious diseases Society of America (IDSA), surgical infection Society (SIS). Clinical practice guidelines for antimicrobial prophylaxis in surgery.
        Surg Infect. 2013 Feb; 14: 73-156
        • Claessen F.M.A.P.
        • Braun Y.
        • van Leeuwen W.F.
        • Dyer G.S.
        • van den Bekerom M.P.J.
        • Ring D.
        What factors are associated with a surgical site infection after operative treatment of an elbow fracture?.
        Clin Orthop Relat Res. 2016 Feb; 474: 562-570
        • Berríos-Torres S.I.
        • Umscheid C.A.
        • Bratzler D.W.
        • Leas B.
        • Stone E.C.
        • Kelz R.R.
        • et al.
        Centers for Disease Control and Prevention guideline for the prevention of surgical site infection, 2017.
        JAMA Surg. 2017 Aug 1; 152: 784-791
        • Honda H.
        • Murakami S.
        • Tokuda Y.
        • Tagashira Y.
        • Takamatsu A.
        Critical national shortage of cefazolin in Japan: management strategies.
        Clin Infect Dis. 2020 Oct 23; 71: 1783-1789
        • Komagamine J.
        • Yabuki T.
        • Hiraiwa T.
        A trend in prevalence of antimicrobial use and appropriateness of antimicrobial therapy in an acute care hospital from 2018 to 2019: repeated prevalence surveys in Japan.
        BMC Res Notes. 2019 Dec 18; 12: 811
        • Metsemakers W.J.
        • Morgenstern M.
        • McNally M.A.
        • Moriarty T.F.
        • McFadyen I.
        • Scarborough M.
        • et al.
        Fracture-related infection: a consensus on definition from an international expert group.
        Injury. 2018 Mar; 49: 505-510
        • Centers for Diseases Control and Prevention
        Surgical site infection (SSI) events.
        (Retrieved from)
        • Kanda Y.
        Investigation of the freely available easy-to-use software “EZR” for medical statistics.
        Bone Marrow Transplant. 2013 Mar; 48: 452-458
        • Nakarai H.
        • Yamada K.
        • Tonosu J.
        • Abe H.
        • Watanabe K.
        • Yoshida Y.
        • et al.
        The impact of cefazolin shortage on surgical site infection following spine surgery in Japan.
        Spine. 2021 Jul 15; 46: 923-930
        • Zelenitsky S.A.
        • Beahm N.P.
        • Iacovides H.
        • Ariano R.E.
        • Zhanel G.
        Limitations of ceftriaxone compared with cefazolin against MSSA: an integrated pharmacodynamic analysis.
        J Antimicrob Chemother. 2018 Jul 1; 73: 1888-1894
        • Carr D.R.
        • Stiefel U.
        • Bonomo R.A.
        • Burant C.J.
        • Sims S.V.
        A comparison of cefazolin versus ceftriaxone for the treatment of methicillin-susceptible Staphylococcus aureus bacteremia in a tertiary care VA Medical Center.
        Open Forum Infect Dis. 2018 May 18; 5: ofy089
        • Li K.
        • Sambare T.D.
        • Jiang S.Y.
        • Shearer E.J.
        • Douglass N.P.
        • Kamal R.N.
        Effectiveness of preoperative antibiotics in preventing surgical site infection after common soft tissue procedures of the hand.
        Clin Orthop Relat Res. 2018 Apr; 476: 664-673
        • Bykowski M.R.
        • Sivak W.N.
        • Cray J.
        • Buterbaugh G.
        • Imbriglia J.E.
        • Lee W.P.A.
        Assessing the impact of antibiotic prophylaxis in outpatient elective hand surgery: a single-center, retrospective review of 8,850 cases.
        J Hand Surg Am. 2011 Nov; 36: 1741-1747