Efficacy of Antibiotic Suppressive Therapy in Patients with a Prosthetic Joint Infection

Abstract

Introduction: For chronic prosthetic joint infections (PJI), complete removal of the infected prosthesis is necessary in order to cure the infection. Unfortunately, a subgroup of patients is not able to undergo a revision surgery due to high surgical risk. Alternatively, these patients can be treated with antibiotic suppressive therapy (AST) to suppress the infection. Aim: To evaluate the efficacy and tolerability of AST. Methods: We retrospectively collected data (period 2009-2015) from patients with a PJI (of hip, knee or shoulder) who were treated with AST at the University Medical Center Groningen, the Netherlands. AST was defined as antibiotic treatment for PJI that was started after the usual 3 months of antibiotic treatment. The time of follow-up was defined from the time point AST was started. Treatment was considered as failed, when the patient still experienced joint pain, when surgical intervention (debridement, removal, arthrodesis or amputation) was needed to control the infection and/or when death occurred due to the infection. Results: We included 21 patients with a median age of 67 years (range 21 - 88) and with a median follow-up of 21 months (range 3 - 81). Coagulase negative staphylococci (CNS) (n=6), S. aureus (n=6) and polymicrobial flora (n=4) were the most frequently found causative pathogens. Most patients with CNS and S. aureus were treated with minocycline (67%) and clindamycin (83%) as AST, respectively. Overall, treatment was successful in 67% of patients. Failure was due to persistent joint pain (n=1), surgical intervention because of an uncontrolled infection (n=3), and death due the infection (n=3). We observed a treatment success of 90% in patients with a 'standard' prosthesis (n=11), compared to only 50% in patients with a tumor-prosthesis (n=10). Also, treatment was successful in 83% of patients with a CNS as causative microorganism for the infection, compared to 50% in patients with a S. aureus. Patients who failed on AST had a higher ESR in comparison to patients with a successful treatment (mean 73 ± 25SD versus 32 ± 19SD mm/hour (p = 0.007), respectively. 43% of patients experienced side effects and led to a switch of antibiotic treatment or a dose adjustment in almost all of these patients. Conclusions: Removal of the implant remains first choice in patients with chronic PJI. However, AST is a reasonable alternative treatment option in a subgroup of patients with a PJI who are no candidate for revision surgery, in particular in patients with a 'standard' prosthesis and/or CNS as the causative micro-organism.

Clinical Outcome of Antibiotic Suppressive Therapy in Patients with a Prosthetic Joint Infection after Hip Replacement

“…To describe overall survival without an event, a Kaplan-Meier survival analysis was performed according to an intention-to-treat principle. To assess the association of risk factors, known from previous studies [8][9][10][11][12][13], with clinical outcome, a univariate logistic regression analysis was performed. In case off missing values these data were deleted from our analysis.…”

“…Considering an estimated mean survival of 82 months (95% CI 54-111), AST appears to be a rational treatment option when curative treatment seems impossible. Success rate in previous studies vary from 23 to 86% [6][7][8][9][10][11][12][13]. Table 4 summarizes the results of previous studies reporting on AST [8][9][10][11][12][13].…”

“…In other previously published literature, several variables associated with a lower chance of survival are described; S. aureus infection [8,9,10,12], older age (>85 years), female gender, hypoalbuminemia, presence of a sinus tract [10], tumor prosthesis, higher level of inflammation blood values, rheumatoid arthritis [12], longer initial curative treatment and discontinuation of AST after 2 years [13]. We performed a univariate logistic regression analysis for all of these variables as described in Table 3.…”

“…Previous studies regarding AST in PJI are few. We have found a total of eight studies reporting clinical outcome of PJI patients treated with AST between 1988 and 2017 [6][7][8][9][10][11][12][13]. These studies included 13-92 patients treated with a variety of suppressive antibiotics, reporting success rates varying from 23% to 86% with a mean follow-up of 2-5 years.…”

“…These studies included 13-92 patients treated with a variety of suppressive antibiotics, reporting success rates varying from 23% to 86% with a mean follow-up of 2-5 years. These studies on AST give us variable data on AST in mostly inhomogeneous groups with PJI of hip, knee, shoulder and elbow joints, different type, dosage and duration of antibiotic therapy with relatively short follow-up [6][7][8][9][10][11][12][13].…”