Successful treatment of prosthetic joint infections often requires multiple surgical interventions and prolonged antimicrobial therapy. However, in certain situations, a surgical approach may not be in the best interest of the patient. A conservative approach was used to treat 34 patients with prosthetic joint infection between 1995 and 2003. Diagnosis of infection was based on clinical-microbiological evidence, confirmed by (99)Tc-labelled leukocyte scintigraphy, and involved 12 Staphylococcus aureus infections, nine Staphylococcus epidermidis infections, two Enterococcus faecalis infections, two mixed infections (S. aureus plus Pseudomonas aeruginosa; S. epidermidis plus E. faecalis), with the infecting pathogen being unidentified for nine patients. Most infections were treated initially with intravenous or intramuscular teicoplanin +/- ciprofloxacin or rifampicin, followed by oral ciprofloxacin or minocycline plus rifampicin. The mean duration of antimicrobial therapy was 41.2 weeks. Overall, only three patients did not respond to therapy, and infection was controlled in the remaining 31 patients. Among these, no relapse was observed in 17 patients during follow-up for 9-57 months; improvement with early (within 6 months of antibiotic discontinuation) or late relapse was observed in seven and three patients, respectively; two patients improved clinically, but continued to receive antibiotic therapy; and two patients whose condition improved initially were lost after a 6-month follow-up following discontinuation of antibiotics. No patient complained of side effects requiring discontinuation of antibiotic therapy. The study confirmed that suppression of infection, with salvage of the infected device in an acceptably functional state, can be achieved in selected cases.

The conventional therapeutic approach to bone infection associated with osteosynthesis is based on the idea that microbial eradication is most readily achieved by removal of the foreign material together with adequate antimicrobial therapy. This strategy usually requires implantation of external fixation devices with additional discomfort to the patient. We report our experience with conservative medical and antimicrobial therapy without removal of the osteosynthesis until adequate bone callus deposition is documented by bone radiography scan. Twenty patients with infections associated with intramedullary nailing (9 patients), screws and plate (9 patients) or screws (2 patients) were treated between 1995 to 2000. Osteosynthesis implantation sites were tibia (7 patients), femur (6 patients), femur and tibia (1 patient), humerus (1 patient), others (5 patients). Diagnosis of infection was based on clinical-microbiological evidence and confirmed by 99Tc-labeled leukocyte scan studies. Offending pathogens were Staphylococcus aureus 17 cases, Staphylococcus aureus + Escherichia coli, Staphylococcus epidermidis, unknown, 1 case each. Most infections were initially treated with intravenous or intramuscular teicoplanin +/- ciprofloxacin or rifampin followed by oral antimicrobial therapy usually with ciprofloxacin or minocycline plus rifampin. Mean duration of antimicrobial therapy was 27.7 weeks (range 12-64 weeks). All patients (100%) were cured, and none complained of side-effects requiring antibiotic therapy discontinuation. We conclude that conservative medical therapy is feasible for osteosynthesis-associated bone infection.

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