Is prolonged systemic antibiotic treatment essential in two-stage revision hip replacement for chronic Gram-positive infection?

Abstract

When using a staged approach to eradicate chronic infection after total hip replacement, systemic delivery of antibiotics after the first stage is often employed for an extended period of typically six weeks together with the use of an in situ antibiotic-eluting polymethylmethacrylate interval spacer. We report our multi-surgeon experience of 43 consecutive patients (44 hips) who received systemic vancomycin for two weeks in combination with a vancomycin- and gentamicin-eluting spacer system in the course of a two-stage revision procedure for deep infection with a median follow-up of 49 months (25 to 83). The antibiotic-eluting articulating spacers fractured in six hips (13.9%) and dislocated in five patients (11.6%). Successful elimination of the infecting organisms occurred in 38 (92.7%) of 41 hips with three patients developing superinfection with a new organism. We conclude that prolonged systemic antibiotic therapy may not be essential in the two-stage treatment of a total hip replacement for Gram-positive infection, provided that a high concentration of antibiotics is delivered locally using an antibiotic-eluting system.

The Fate of Spacers in the Treatment of Periprosthetic Joint Infection

“…This study, specifically designed to evaluate the clinical course of patients in between two stages, demonstrated that almost one-fifth of patients who underwent resection arthroplasty and spacer insertion did not undergo a subsequent reimplantation. Within the literature, there is considerable variation in the reimplantation rates following explantation, ranging from 28.6% 24 to 100% [25][26][27][28][29] , and most studies have demonstrated reimplantation rates above 80% 1,2,5,[30][31][32][33][34] . Failure to reimplant may occur for a variety of reasons, including mortality, medical comorbidity, patients lost to follow-up, patients satisfied with their current level of function in the setting of a retained spacer 19 , and persistent infection that may ultimately result in definitive treatment with amputation, arthrodesis, or lifetime antibiotic suppression.…”

The use of spacers (static and mobile) in infection knee arthroplasty

“…Patients receive specific oral or intravenous antibiotic therapy, or both, targeted toward bacteria isolated during the first-stage surgery [11]. Although the ideal duration for antibiotic therapy is not defined, most of the recent literature recommends a 6-to 12-week course [12][13][14][15]. Once the infection is eradicated, and CRP and ESR levels return to normal, the second surgery is performed to remove the spacer and implant the revision prosthesis.…”

Infection in total hip replacement: meta-analysis

“…Two patients (2.4%) had allergic reactions to the intravenous antibiotic therapy and acute renal failure occurred in five cases (6%). Increased complications can be expected with single sized spacers, especially without endoskeleton reinforcement [41,43].…”

“…Whittaker et al [41] reviewed 43 patients (44 spacers) who received systemic vancomycin only for two weeks in combination with a vancomycin-and gentamicin-eluting spacer system. The infection-free rate was 92.7% at a mean follow-up of 49 months.…”