If, When, and How to Use Rifampin in Acute Staphylococcal Periprosthetic Joint Infections, a Multicentre Observational Study

Abstract

Background Rifampin is generally advised in the treatment of acute staphylococcal periprosthetic joint infections (PJI). However, if, when, and how to use rifampinremains a matter of debate. We evaluated the outcome of patients treated with and without rifampin, and analyzed the influence of timing, dose and co-antibiotic. Methods Acute staphylococcal PJIs treated with surgical debridement between 1999 and 2017, and a minimal follow-up of 1 year were evaluated. Treatment failure was defined as the need for any further surgical procedure related to infection, PJI-related death or the need for suppressive antimicrobial treatment. Results A total of 669 patients were analyzed. Treatment failure was 32.2% (131/407) in patients treated with rifampin and 54.2% (142/262) in whom rifampin was withheld (P < 0.001). The most prominent effect of rifampin was observed in knees (treatment failure 28.6% versus 63.9%, respectively, P < 0.001). The use of rifampin was an independent predictor of treatment success in the multi-variate analysis (OR 0.30, 95% CI 0.20 – 0.45). In the rifampin group, the use of a co-antibiotic other than a fluoroquinolone or clindamycin (OR 10.1, 95% CI 5.65 – 18.2) and the start of rifampin within 5 days after surgical debridement (OR 1.96, 95% CI 1.08 – 3.65) were predictors of treatment failure. The dosing of rifampin had no effect on outcome. Conclusions Our data supports the use of rifampin in acute staphylococcal PJIs treated with surgical debridement, particularly in knees. Immediate start of rifampin after surgical debridement should probably be discouraged, but requires further investigation.

Delayed Rifampin Administration in the Antibiotic Treatment of Periprosthetic Joint Infections Significantly Reduces the Emergence of Rifampin Resistance

“…However, the authors could not evaluate the causality of developing resistances on this association since no microbiological data had been collected on the development of pathogen resistance. Our results significantly confirm the association between immediate start of rifampin after surgical revision and emergence of rifampin resistance, which may explain the effect on treatment failure rates seen in the study of Beldman et al [17].…”

“…A more recent multi-center study published by Beldman et al [17] in 2021 investigated the outcome of a large cohort of 669 patients with acute staphylococcal PJI and found a significant advantage of antibiotic treatment involving rifampin. In their study, the treatment failure rates increased from 32.2% (131/407 cases) with additional rifampin to 54.2% (142/262) without additional rifampin.…”

“…Beldman et al [17] reported an association between immediate start of rifampin therapy and treatment failure. However, the authors could not evaluate the causality of developing resistances on this association since no microbiological data had been collected on the development of pathogen resistance.…”

Truth in DAIR: Duration of Therapy and the Use of Quinolone/Rifampin-Based Regimens After Debridement and Implant Retention for Periprosthetic Joint Infections

“…For staphylococcal PJI, most studies and guidelines support the use of rifampin-combination therapy [ 11 , 26 ]. This study confirms the findings of Beldman et al [ 26 ], showing that there are outcome benefits to using a rifampin-based regimen, particularly with knee PJIs.…”

Rifampin for Staphylococcal Prosthetic Joint Infection: Do We Still Need a Randomized Controlled Trial?

“…T o the Editor —With great interest we read the observational study by Beldman et al [ 1 ] in which the additional value of rifampin for patients with staphylococcal prosthetic joint infection (PJI) was evaluated. Their data show a favorable effect of rifampin after adjustments.…”