One hundred and twelve infected arthroplasties treated with 'DAIR' (debridement, antibiotics and implant retention): antibiotic duration and outcome

Abstract

ObjectivesWe describe treatment failure rates by antibiotic duration for prosthetic joint infection (PJI) managed with debridement, antibiotics and implant retention (DAIR).MethodsWe retrospectively collected data from all the cases of PJI that were managed with DAIR over a 5 year period. Surgical debridement, microbiological sampling, early intravenous antibiotics and prolonged oral follow-on antibiotics were used.ResultsOne hundred and twelve cases of PJI were identified. Twenty infections (18%) recurred during a mean follow-up of 2.3 years. The mean duration of antibiotic use was 1.5 years. Failure was more common after arthroscopic debridement, for previously revised joints and for Staphylococcus aureus infection. There were 12 failures after stopping antibiotics and 8 while on antibiotics [hazard ratio (HR) = 4.3, 95% confidence interval (CI) 1.4–12.8, P = 0.01]. However, during the first 3 months of follow-up, there were eight failures after stopping antibiotics and two while on antibiotics (HR = 7.0, 95% CI 1.5–33, P = 0.015). The duration of antibiotic therapy prior to stopping did not predict outcome.ConclusionsPJI may be managed by DAIR. The risk of failure with this strategy rises after stopping oral antibiotics, but lengthening antibiotic therapy may simply postpone, rather than prevent, failure.

Prosthetic Joint Infection

“…This is supported by the finding that the risk of failure increases 4-fold after antimicrobials are stopped, with most failures occurring in the first 4 months after antimicrobials are stopped (349). Conversely, others suggest that therapy can be stopped in an asymptomatic patient with a normal CRP result and negative nuclear medicine imaging results (352).…”

“…Stability of the prosthesis is assessed intraoperatively, typically followed by removal and replacement of any exchangeable components such as the polyethylene liner or a modular femoral head. The entire joint is then aggressively irrigated and closed, typically over a drain (348,349). Arthroscopic DAIR procedures have also been reported, but adequate debridement is more difficult, and outcomes may be suboptimal.…”

“…Arthroscopic DAIR procedures have also been reported, but adequate debridement is more difficult, and outcomes may be suboptimal. One study found a Ͼ4-fold increase in the risk of treatment failure when arthroscopic debridement was performed compared to an open procedure (349). Open debridement should therefore be performed whenever possible.…”

“…After pathogen identification and antimicrobial susceptibility are defined, antimicrobial therapy can be tailored. Most clinicians use intravenous antibiotics for the first 2 to 6 weeks following a DAIR procedure (102,127,(348)(349)(350)(351). Recent IDSA guidelines suggest that 4 to 6 weeks of intravenous therapy should be used with PJI due to organisms other than staphylococci or when rifampin combination therapy cannot be used (60).…”

Staphylococcus aureus Infections: Epidemiology, Pathophysiology, Clinical Manifestations, and Management

“…aureus is the most common pathogen in all three major classes of osteoarticular infection, namely, osteomyelitis (OM) (382)(383)(384)(385)(386)(387)(388)(389)(390)(391)(392), native joint septic arthritis (393)(394)(395)(396)(397)(398)(399)(400)(401), and prosthetic joint infection (PJI) (402)(403)(404)(405)(406). As staphylococcal osteoarticular infections in children are common and have distinctive clinical and management issues compared to those in adults, we include an in-depth discussion of this important subpopulation.…”